STUDENT QUESTIONNAIRE

We are requesting this information to help ensure your safety and wellbeing whilst studying
with us. The information will be stored confidentially and will be shredded when you’ve
completed your training with us.
Further explanation is provided in the notes at the end of the form.
If you do not wish to provide the information, please indicate in the box.

Name : MD SHAMIM Contact number: +91 8420450654

Do you have any health conditions we need to be aware of? Please describe.1

N/A

Are you currently taking any medication? Please describe.2

N/A

Do you have a disability or require special assistance to avail our facilities or training?
Please describe any reasonable support we can provide. 3

N/A

Do you have any allergies, including food allergies? Please list and tell us how we should
treat a reaction if it occurs e.g. Epi-pen.4

N/A

Blood group (if known): A+

If travelling by your car, and parking at TWI premises5: N/A

Driving licence number (please provide copy)

Insurance details
Vehicle pollution certificate number
Emergency contact details6

Name : Reshma Khatoon

Relationship: Wife
Full contact number incl. area and country code. +91 8910313328

For foreign students only

Name :
Passport No:
Nationality :
Student visa / X MISC visa :

Visa number Expiry date

Sponsor details

Medical insurance details

Provider name
Contact number
Policy number
Expiry date

Signed……………………………………………….. Date ……………………

1
Should you become ill, this information may be useful to our staff if they need to administer First Aid.
2
Should you become ill, this information may be useful to our staff if they need to administer First Aid.
However, please note our staff will not administer medication for you
3
We will make any reasonable accommodations regarding facilities, equipment, and access to resources, in
accordance with the Rights of People with Disabilities Act 2016.
4
We will try to provide alternative food arrangements if you have a food allergy
5
If you are travelling in your own vehicle and wish to park it on TWI premises, you must possess a valid driving
licence and your vehicle must be roadworthy and legal.
6
In the evet of an emergency or sudden illness/accident, we will attempt to notify this person.