UCSA Advocacy & Welfare Intake Form

Personal Details

• Name:

  First

  Last

• Contact Phone Number:
• Email:
• Do you identify with any of the following groups?
  Rainbow Community
  Māori
  Pasifika
• What religion do you identify with, in any?



Student information

• Student ID Number:
• Are you:
  Domestic
  International
• Faculty:
  Arts
  Business
  Education
  Engineering
  Health
  Law
  Science
  
• Degree & Major:
• Year of Study:

  e.g. 1st Year, 2nd Year etc.

• Do you recieve a Manaaki/NZ Aid Scholarship?
  Yes
  No

What would you like to talk about?

• General Enquiry
  Appeal
  Complaint / Grievance
  Discipline / Proctor
  UC Special Consideration process
  Academic Progress / Exclusion
  

Case Information

• Please provide details of your circumstances
• For us to best assist you with the matter you have described above, pleast attach the following documents:
  • A copy of your UC internal transcript
  • Copies of emails and correspondence with UC staff members reguarding the issue, including attachments
  • Medical Certificates
  • Any other relevent documents
• Please attach any relevent documents here:

Privacy Declaration

• The personal information you provide in this document is protected by the Privacy Act 2020. It will be shared with relevant UCSA staff only, unless you provide consent for UCSA staff to contact any other party. Your information will not be used for any other purpose than compiling statistics (auditing, reporting, etc).
  I have read, understood, and accept the privacy statement.