Client Registration & Request for Support - Form

Clear Links Support Ltd uses the term �client� to refer to the people we support.

Please Note: The Client Registration & Request for Support form can be completed by you, or by a person on your behalf, for example a disability adviser at university or work colleague.

In accordance with UK Data Protection legislation, Clear Links Support Ltd will hold, process and use your data exclusively to provide you with the service for which you registered. Completing our registration form signifies consent to us collecting personal information. It also confirms your agreement that Clear Links Support Ltd may pass on relevant information to all those involved in the support work process.

The bracketed letters or symbols are accesskeys to enable you to navigate the text boxes without using the mouse. How to use the access keys:

On a Windows system: Hold down the ALT key on the keyboard and, with this held down, press the letter or symbol key you can see in brackets next to the field you wish to complete.

On a Mac system: Hold down the CTRL key on the keyboard and, with this held down, press the letter or symbol key you can see in brackets next to the field you wish to complete.

You can also use the TAB key to move down the fields, or SHIFT TAB key to move up the fields.

Fields with an asterisk * must be completed.

Personal Information Title* (a):
First name* (b):
Last name* (c):
Date of Birth* (e):
ART ID (f):

Contact Details

Term Time Address

Address line 1* (h):
Address line 2 (i):
Town / City* (j):
County (k):
Post code* (l):
Telephone No* (m):
Mobile No* (n):

Please enter a university email address that you will continue to use in email address 1. You can enter a second email address in email address 2 or you can leave this blank.

Email address 1* (o):
Email address 2 (p):

Home Address

Please tick the box if the home address is the same as the

term time address (q):

Address line 1 (r):
Address line 2 (s):
Town/City (t):
County (u):
Post code (v):
Telephone No (w):

Client University and Course Details University / Campus* (x):
Course Title* (y):
Year of Study* (z):
Course end date* (2):

Request for Support Work Reason a support worker required (4):

In this section you can select up to five support worker roles. For each of the support worker roles you require please complete the relevant details. If you require more than five support worker roles please tell us in the Additional Information section below.

1. Support Required (5):
Hrs per week :
Weeks per year :
Support end date :

2. Support Required :
Hrs per week:
Weeks per year:
Support end date:

3. Support Required:
Hrs per week:
Weeks per year:
Support end date:

4. Support Required:
Hrs per week:
Weeks per year:
Support end date:

5.Support Required:
Hrs per week:
Weeks per year:
Support end date:

Please note that Clear Links Support Ltd will be required to confirm with the funding body that this level and amount of support has been approved

Funding details Funding Body* (6):
Contact person at funding body (7):
Evidence provided of funding availability (8):

Please attach Needs Assessment or letter of funding approval if available by clicking browse and attaching a file. The file must have a .doc or .pdf extension Upload funding evidence (9):

Additional information

Information for the support worker. This information will be supplied to the support worker on the assignment confirmation.

Information for the support worker (,):

Information for Clear Links Support Ltd. This information will not be passed to the worker but may be used by Clear Links Support Ltd to select appropriate workers.

Information for Clear Links Support Ltd (.):

Please read the Service Level Agreement and Data Protection Policy and click in the boxes to accept

Service Level Agreement* (-): (opens in new window):

Data Protection policy* (#): (opens in new window):

Client Terms of Business* (1): (opens in new window):

You will also need to read and accept the �Client Terms of Business� which constitute the contract between Clear Links and the Client for the supply of the Support Worker�s Services by Clear Links to the Client. The terms are deemed to be accepted by the Client by a request for the use of a Support Worker or by registering on the Clear Links website, whichever is the earliest.

Submitted by (=):
Date (;):