TUTOR REQUEST FORM

Name:		Student ID#:
Major:		Date:
Phone #:	home   Work:	email:

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Are you involved in any of the following programs? Please check all that apply:

EOPSFinancial AidLearning DisabilitiesESLEarly AlertDSP&S

Please indicate the classes in which you need tutoring:

Class name (eg: Bio 1)	Days	Time	Instructor

Please indicate which days and times are best for you to be tutored:

Day	Time	Day	Time

Please briefly describe your reasons for seeking tutoring:

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Are you enrolled in TU 301?       YesNo

If not, please enroll in TU 301 at Admissions before submitting this form.

In order for you to receive English tutoring, you must be enrolled in Writing 180 and attend regularly.
You must bring a referral from your WR 180 instructor before you can be tutored.

Are you enrolled in Writing 180?    YesNo

In order for you to receive Math tutoring, you must be enrolled in the Math Lab and attend regularly.
You must bring a referral from your Ma 180 or 280 instructor before you can be tutored.

Are you enrolled in Math 180/280?      YesNo

I have read the student agreement, and I understand my responsibilities as a participant in the Learning Center.