DSA £200 Contribution Fund Application Form

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1) Name

2) University ID number

3) Customer Reference Number (for Student Finance England)

4) Email address

5) Telephone number

Yes

I understand the terms and conditions of the scheme listed at http://www.warwick.ac.uk/services/tutors/disability/allowances.

I confirm that the information I have supplied is complete and accurate and I understand that I may be asked to repay any funds I have received if the information supplied is later found to be incorrect or incomplete.

*Please attach your DSA2 agreement letter outlining the requirement for you to make the £200 contribution. Please also provide a receipt confirming you have paid the £200 contribution (the receipt must be from the equipment provider and clearly show the amount you have paid and your full name). If you are applying for Level 2 support please attach a copy of your benefit/ tax credit notification.*

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Privacy notice

The University of Warwick will process your personal data provided in this application form for the purposes of processing your application and assessing your eligibility for the DSA £200 Contribution Fund.

The legal basis for processing this personal data is that it is necessary for the performance of services and/or consent, which is obtained through your submission of this online form.

Your personal data will not be shared or disclosed to any third parties external to the University of Warwick.

Your personal data will not be transferred outside of the EEA, will be kept securely by the University of Warwick and will be retained for as long as the current academic year plus six years.

The University of Warwick is the Data Controller of this information and is committed to protecting the rights of individuals in line with Data Protection Legislation. Please visit the University’s Data Protection webpages for further information in relation to your rights and how the University processes your personal data. The University has a Data Protection Officer who can be contacted by emailing dpo@warwick.ac.uk. Any requests or complaints should be made in writing to the University's Data Protection Officer.

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.

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DSA £200 Contribution Fund Application Form

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