Learning Assistance Center

Tutoring Intake Form

Please fill out the form below to sign up for the Tutoring Intake Form. All fields marked with an * are required.

Name*

Banner ID*

E-Mail*

Phone*

Subject (please include department and course number -- i.e. BIOL 160)*

Professor*

Current Grade in Class*

Year in School*

Major*

Referred by...*

Name of person who referred you*

Are you a transfer student?* Yes   No

Are you a CAPS student?* Yes   No

Are you a participant in Freshman Success?* Yes   No

Are you a Full Time student?* Yes   No

Are you a participant in Student Support Services?* Yes   No

Are you an International student?* Yes   No

Could we notify your professor that you are receiving tutoring?* Yes   No

Have you requested tutoring before?* Yes   No

What do you have difficulties with in this class? What are you looking for help with?*

Results of Learning Style Inventory

I have never requested a tutor from the LAC before.

Click here to get a graphic version of the inventory. Print it out, take it and score it. Record scores here:

Visual:
Auditory:
Tactile:
Kinesthetic:

I have requested a tutor from the LAC before, and therefore, my results from the Learning Style Inventory are on file.

Tutoring Environment Information

Please check any that apply to you.

I CANNOT work with any distractions (noise or people moving about, occasionally talking quietly).

I CANNOT work in complete silence.

I CANNOT work without lots of natural light.

I CANNOT work in a bright room.

I'm flexible, I can concentrate fairly well in most light and noise environments.

I don't know.

Scheduling Information

Please list the time slots that you are available for tutoring during the upcoming week. Start with TOMORROW and end with a week from today.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Comments

Other Comments

By submitting this form, I agree to come to my tutoring sessions prepared with books, notes, syllabus, and other class materials. I also agree to be prompt to my appointments, and will give my tutor 24 hour notice if I cannot make a scheduled appointment. I understand that the tutor will document any "stand ups" and I will be notified if there are any concerns about my attendance.