This form is for Centres to complete with any Reasonable Adjustment requests.Please read the Reasonable Adjustments and Special Consideration – Centre Guidance before completing this form.Reasonable Adjustments Request Form Please complete all fields and submit the form no later than ten working days before the assessment Centre Name*Centre No.*The cohort(s) and/or learner(s) to whom you wish to apply Special Considerations* Enter Cohort IDs or Learner Numbers. Please do not include learner names. Click + sign to add more rows.Qualification Number*Qualification title (learner is registered on)*Reason for application*Access arrangement requested*Details of supporting evidence*Please provide details of supporting evidence below, this may include: • The centre’s assessment of the learner’s needs • History of provision for the learner within the centre • Medical certificate • Psychological or other professional assessment reportPlease upload supporting evidence, if relevant Drop files here or DECLARATION: I am satisfied that the information provided on this form is accurate. I fully support the application and confirm that the learner is/will be appropriately entered for the examination(s)/course(s) concerned and will be able to demonstrate the assessment objectives required by the specification.* First Last Date* DD MM YYYYEmail*We will email you confirmation of this request. At Gateway Qualifications we are committed to protecting the personal information we are trusted with and respecting the privacy of those whose information we hold. We process your personal data as set out in our Privacy Notice which we encourage you to read.