My Account Information

Title:	Mr    Mrs    Miss    Ms    Dr    Prof  *
First Name:	* as it appears on your passport
Last Name:	* as it appears on your passport
Gender:	Male    Female    Other  *
Date of Birth:	* (dd/mm/yyyy) Please note you must be 18 or over to enrol.

Have you studied with Open Learning before?   Yes   No   *

Street Address:	*
Town/City:	*
Post Code:	*
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Daytime Number:	* include area code
Evening Number:	* include area code
Email Address:	*

Do you have a disability? *

No known disability  A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D  A social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder  A long standing illness or health condition such as a cancer, HIV, diabetes, chronic heart disease, or epilepsy  A mental health condition, such as depression, schizophrenia or anxiety disorder  A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches  Deaf or a serious hearing impairment  Blind or a serious visual impairment uncorrected by glasses  A disability, impairment or medical condition that is not listed

If as a result of your disability you have support requirements, please complete a support needs form and return it 3 weeks before your class commences. The form is available to download from the Open Learning website under the Facilities for Disabled Students: New Protocol section.

Full    Pensioner Rate    State Benefit     Student    QUB Staff   *

Password:	*
Password Confirmation:	*

The information provided on this form will be added to our Open Learning database, which is held securely by Queen's University Belfast, and will be treated confidentially. We will only use this information to provide you with the services you have enrolled for.

Do you wish to be contacted in relation to other Open Learning courses or receive any future brochures?  Yes   No   *

Your details will only be used for mailing information on Open Learning courses and will not be passed on to other bodies. You may unsubscribe from this mailing list at any time by contacting openlearning.education@qub.ac.uk or 9097 3323.