| |
| Student First Name: |
|
| Student Last Name: |
|
| Student ID number: |
|
| Course Name: |
|
| Section Number: |
= |
| Instructor's Name: |
|
| |
|
| Have you spoken directly with the student? |
| Yes No - If yes, how many times? |
| |
|
| The above named student is being referred for assistance in the following area(s) – please check all that apply |
| Low test scores |
Student not doing homework |
| Poor study habits |
Poor classroom attendance |
| Needs financial assistance |
Student does not have books |
| Child care issues |
Highly recommend tutoring |
| Poor classroom participation |
Disruptive in class |
| Poor attention span in class |
Student is late to class |
| Student leaves class early |
Cell phone use is an issue |
| Needs writing assistance |
Not prepared for class |
| Talks too much (not class-related) |
Needs English/reading assistance |
| Needs bilingual assistance |
Needs spelling assistance |
| Needs vocabulary assistance |
|
| Other: |
| Please make any additional comments or recommendations you feel would assist us in making the best referral |
|
| |
| |
| Thank you! |
|
|
APPLY ONLINE REGISTER FOR CLASSES 
