Tutor Request Form

Name Date
Social Security Number
Hall Room Number Extension Major
Year: FR SO JR SR
Course and Number Instructor
Present Grade: A B C D F No Test Yet
Have you spoken to your instructor about your difficulty in the course? Yes No
Will you inform your instructor that you are receiving tutoring? Yes No
Do you attend class regularly? Yes No
Would you like to meet with the tutor for just one session? Yes No
Would you like to meet on a regular basis, such as once a week? Yes No
What kind of help would you like? Reviewing Notes Homework Assignments Studying for a test (When is the test? )
Other:
Please list best days and times for tutoring

Any other comments:

In order to recieve tutoring, I understand that I must

1. Attend Classes regularly,
2. Come prepared to tutoring sessions, and
3. Inform my tutor when I cannot make a scheduled session.