Student Equity Registration Form
To register for disability support
Social Justice, Equity and Inclusion require documentation of your disability, injury, mental health
or medical condition in order to register you for disability support. The documentation enables us to
assess and provide if necessary, appropriate services in relation to your studies. Social Justice,
Equity and Inclusion stores your confidential and personal information supplied by you or others in
electronic databases with access restricted to authorised staff only.
From time to time, Social Justice, Equity and Inclusion may need to communicate with other staff
within the University and external third parties regarding your disability/condition, reasonable
adjustments, services, support issues and arrangements.
Use and disclosure of confidential information agreement:
I, (print full name):
USQ Student Number:
Hereby give permission for Social Justice, Equity and Inclusion to register me for disability support
and communicate with relevant University staff when necessary to assist me in negotiating and
arranging supports and services during the course of my studies. This information may be conveyed
verbally, in writing or electronically.
Please tick the appropriate box to indicate your level of consent (choose one option only):
I also give permission for Social Justice, Equity and Inclusion staff to contact my relevant Health
Practitioner to seek further information or clarification in relation to the information I have provided
regarding my condition.
I understand that I can revoke this consent at any time by contacting Social Justice, Equity and
Inclusion. I understand that if I do not agree to give these permissions, it may hinder the university’s
ability to provide relevant learning supports.
Please email a copy of this completed form to firstname.lastname@example.org 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.
1. ☐ I give permission for Social Justice, Equity and Inclusion staff to have full disclosure and release
the name of my condition and its impact on my studies to relevant staff at the University of
2. ☐ I give permission for Social Justice, Equity and Inclusion staff to release only the impact of my
condition on my studies to relevant staff at the University of Southern Queensland
3. ☐ I do not wish for the name of my condition or its impact on my studies to be discussed with
relevant staff at University of Southern Queensland (No disclosure)