FOR OFFICE USE ONLY – ENROLLED IN TUT-106 DATE: ___/___/____ BY ____ __ Revised: 6/30/2015
Tutoring Referral Form
Instructions
1. Student must complete the top portion of this form.
2. Obtain a signature from a counselor or instructor.
3. Turn in your completed form to the Tutorial Center to be scheduled with a tutor.
The Tutorial Center is located in the Communication Building, Room 1.
Student Name: Student ID#:
Phone: Alt Phone:
Semester: 20 Fall Spring Summer
List the courses in which you wish to receive tutoring: (example Math-A or Engl-01A)
1. 2. 3.
Have you developed an educational plan with a counselor? Yes No
Please check the number of hours a week you would like to meet with a tutor (if possible) 1 2 3
Directions: Check the boxes below for the days & times you ARE AVAILABLE for tutoring.
I understand that failing to cancel a tutoring session 24 hours in advance will be considered a NO-SHOW.
Student Initials Two (2) no-shows will result in the student losing the privilege to schedule tutoring appointments and will only be
able to obtain tutoring services on a walk-in basis for the remainder of the semester.
I have read and understand the tutoring guidelines. I agree to arrive on time to each session, to come prepared,
Student Initials and to complete my own work prior to each session.
Student Print Name Student Signature Date
This area must be completed by a counselor or instructor
The supervised tutoring non-credit course (TUT-106) provides learning skills and study skills which are necessary
for the student to succeed in college level work. I recommend this student receive tutoring in order to be successful
in the indicated course(s).
Mathematics English and Reading Study/Learning Skills Other Subject
Please check the subject area above and describe the specific topic(s) the tutor should review with the student.
Counselor/Instructor Print Name Counselor/Instructor Signature Date
