Hardship Fund - Application for Diagnostic Test Reimbursement

{"elements":[{"isDiscrete":false,"hidden":false,"name":"1667378471968_0.2766207317865972_0.08794934631557949","readOnly":false,"id":563559849,"type":"commentElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"He","value":"0-he"},{"text":"She","value":"1-she"},{"text":"They","value":"2-they"},{"text":"Other","value":"3-other"}],"name":"pronoun","readOnly":false,"id":521956913,"type":"checkboxElement"},{"isDiscrete":false,"hidden":false,"name":"other","readOnly":false,"id":521957313,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"First Name","readOnly":true,"id":40767478,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"Last Name","readOnly":true,"id":567083263,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"University ID Number","readOnly":true,"id":40767488,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"University Email Address","readOnly":false,"id":40767534,"type":"textFieldElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Yes","value":"0-yes"},{"text":"No","value":"1-no"}],"name":"Screening","readOnly":false,"id":301904705,"type":"radioElement"},{"isDiscrete":false,"hidden":false,"name":"2) Date of diagnostic assessment (Reimbursement claims can only be accepted within 3 months of the date of your test)","readOnly":false,"id":40767668,"type":"dateTimeElement"},{"isDiscrete":false,"hidden":false,"name":"3) Name of assessor","readOnly":false,"id":40767720,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"4) Cost of test","readOnly":false,"id":40767748,"type":"textFieldElement"},{"isDiscrete":false,"hidden":false,"name":"1757067461387_0.5745656396732526_0.04093232639608857","readOnly":false,"id":40767847,"type":"commentElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"Valid Warwick student ID card.","value":"0-validwarwickstudentidcard."},{"text":"A copy of your diagnostic test invoice. This must be on the test centre's headed company paper and must clearly show the amount you have paid, as well as your name in full and the date of the test.","value":"1-acopyofyourdiagnostictestinvoice.thismustbeonthetestcentresheadedcompanypaperandmustclearlyshowtheamountyouhavepaidaswellasyournameinfullandthedateofthetest."}],"name":"Evidence","readOnly":false,"id":563560229,"type":"checkboxElement"},{"isDiscrete":true,"hidden":false,"values":[{"text":"false","value":"0-false"},{"text":"false","value":"1-false"},{"text":"","value":"2-"},{"text":"false","value":"3-false"},{"text":"false","value":"4-false"}],"name":"Evidence Upload","readOnly":false,"id":41165963,"type":"attachment"}]}

To complete this application, you will first need to be logged into your University account.

She

They

Other

If Other

First Name

Last Name

University ID Number

University Email Address

Yes

2) Date of diagnostic assessment (Reimbursement claims can only be accepted within 3 months of the date of your test)

3) Name of assessor

4) Cost of test

The maximum amount that will be reimbursed is £375.

If the cost of your diagnostic test is more than £375 and you want to apply for the full amount to be reimbursed, you will need to submit a Hardship Fund Expression of Interest form instead. Further information can be found on our Re-imbursement of Diagnostic Assessments webpages.

Valid Warwick student ID card.

A copy of your diagnostic test invoice. This must be on the test centre’s headed company paper and must clearly show the amount you have paid, as well as your name in full and the date of the test.

Evidence Upload

Attach file

No files are currently attached.

Privacy notice

In submitting this form, I can confirm that I have read and understood the below privacy notice.

The legal basis for processing your personal data is consent, which is obtained through your completion of this form.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

Spam prevention

Student Funding Support

Hardship Fund - Application for Diagnostic Test Reimbursement

Failure to load reCAPTCHA