SE-004/1.1
Permission to Advocate
To register for disability support
Please complete this form if you would like to nominate someone (a family member, friend
or formal Advocate) to speak on your behalf to Social Justice, Equity and Inclusion staff.
USQ Student Number:
Full Name:
Hereby gives permission for:
Full Name:
Relationship to you (e.g. parent, spouse):
Contact number of advocate:
Email of advocate:
to communicate with Social Justice, Equity and Inclusion staff as my advocate, in order to
have appropriate support services provided in relation to my studies. This communication
may be conveyed verbally, in writing or electronically.
I understand that I may revoke this consent at any time by advising the Student Equity
Coordinator in writing.
(Student Signature)
(Advocate Signature)
(Signature of Witness)
(Name of Witness)
Date:
Please email a copy of this completed form to disabilitysupport@usq.edu.au and retain
the original for your records.
USQ is collecting the personal information on this form for the purpose of providing the services and assistance
that you have requested. For a full understanding of our privacy information and management of your personal
information, please access our Privacy Statement located at Reception or at www.usq.edu.au/student-support.
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