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Application for intermission form

Visit the on-line Student Handbook on the Intranet for further guidance.

lease note: Academic Registry forms are available on the Moodle home page.

If a different format is required please email StuRecords@chi.ac.uk

SECTION A: TO BE COMPLETED BY STUDENT

Period of intermission requested: This must be a future full period of study, i.e. semester, term or year.

Name of student: Student number:

Title of programme: Year/level of study:

Home address and postcode:

(This should be the address at which you can be contacted during your Intermission)

________________________________________________________________________________________________________________

Last date of attendance at University of Chichester:

_____ /_____ /_____ (Please note that this date will be used by the Finance Department for billing purposes)

Mode of attendance: Full-time

Part-time

Module(s) registered for in this academic year:

Semester 1/Term: Please specify _____

Code: Title:

____________ ________________________________________

Semester 2/Term: Please specify _____

Code: Title:

____________ ________________________________________

I wish to apply for intermission:

From: Semester/Term _____ 20____ Returning: Semester/Term _____ 20____

Please note that it is the applicant’s responsibility to obtain signatures for parts B & C and to keep a copy of this application Page 1 of 2

PTO

Student signature:

Signed:

Dated:

For the following reasons:

Family

Financial

Health

Work

Other

I can confirm I have returned all Library materials/media equipment/other equipment on loan to me

In advance of completing this form we strongly advise you to speak to the Student Adviser and your Academic Adviser or Programme Co-ordinator.

A range of information, advice and counselling services are available and you may find support that can make a real difference to your current situation.

There may be financial implications arising from your decision.

PLEASE NOTE: Retrospective Intermission will not be approved other than exceptionally with supporting documentary evidence by the

Pro Vice-Chancellor.

Student Adviser: Tel: 01243 816238, Email: studentadviser@chi.ac.uk

tudent Money Advice Service: Tel: 01243 806038, Email: stumoneyadv@chi.ac.uk

Student Counselling Service: Tel: 01243 816042, Email: stucounselling@chi.ac.uk

Supportworks number (if applicable)

I confirm that this request is viable and that there will be appropriate subject studies for the student to return to:

Head of Academic Department 1 N

B: Signatures of both HOADs required for joint courses.

Head of Academic Department 2 (if required)

SECTION C: TO BE AUTHORISED BY HEAD OF ACADEMIC DEPARTMENT(S)

Signed: Dated:

Name (please print):

Comments:

Signed: Dated:

Name (please print):

Comments:

Conditions of intermission: NB: These must be non-academic conditions eg medical. Comments

SECTION B: TO BE COMPLETED BY THE PROGRAMME CO-ORDINATOR

Signed: Dated:

Name (Please print):

•

I recommend that this intermission: Is approved

Is not approved

•

Date of intermission

A. I authorise fees for this period to be waived

B. I have seen supporting documentary evidence

SECTION D Only to be completed by Pro Vice-Chancellor if the intermission is retrospective and accompanied by a

request to waive fees, with supporting documentary evidence.

This student is given permission to intermit: Conditionally

Unconditionally

Please note: Once you have obtained the required signatures above, please return the completed form to Academic

Registry, Bishop Otter campus and the authorising signature will be obtained in section D below if required.

From: To:

Please note that it is the applicant’s responsibility to obtain signatures for parts B & C and to keep a copy of this application Page 2 of 2

Pro Vice-Chancellor signature:

Signed:

Dated:

FOR OFFICE USE ONLY

SRS Updated

SLC Informed

CIR emailed

Visa check