Purpose
 London Innovative Studies is committed to providing support and accommodations for students with special learning, medical, or physical needs to ensure an inclusive and accessible learning environment. This form allows students to declare any needs for which they may require additional support or resources during their studies.

Student Information

• Full Name: _______________________________________________
• Student ID: _______________________________________________
• Program of Study: __________________________________________
• Contact Number: ___________________________________________
• Email Address: ____________________________________________

Declaration of Needs

Please indicate the type of support you may need and provide relevant details in the sections below.

1. Learning Needs

(e.g., dyslexia, ADHD, autism, processing challenges)

• Please describe your learning needs:

• Support Required (e.g., extended time, note-taking assistance, assistive technology):

2. Medical Needs

(e.g., diabetes, epilepsy, severe allergies)

• Please describe your medical needs:

• Support Required (e.g., emergency medication storage, access to medical facilities):

3. Physical Needs

(e.g., mobility impairments, vision or hearing difficulties)

• Please describe your physical needs:

• Support Required (e.g., accessible seating, hearing aids, assistive technology):

Supporting Documentation

Please attach relevant documentation from a medical professional or specialist confirming your needs (e.g., medical reports, psychological assessments, or learning support evaluations).

Consent and Confidentiality

London Innovative Studies respects your privacy. Information provided on this form will be treated as confidential and will only be shared with relevant staff to arrange necessary accommodations and support.

• I consent to the information on this form being shared with relevant staff members for the purpose of arranging support and accommodations.
  ( ) Yes
  ( ) No

Student Signature: ____________________Date: _____ / _____ / _____

For Office Use Only

• Received by: _____________________________________________
• Date Received: _____/ ______ / _______
• Action Required: __________________________________________
• Notes:__________________________________________________