Office of Disability Services Tutor Request Form
Academic Skills Center
931-2724
acsk@gsw.edu
PLEASE PRINT CLEARLY!
This form should be completed and turned into Evelyn Oliver, Director of Disability Services and Testing
Semester:
Student ID:
Last Name
Primary Telephone:
First Name
Middle Initial
Alternate Telephone:
RADAR email:
Alternate email:
List all subjects for which a tutor is requested below.
Course Subject Code or
CC
(i.e. MATH 1111)
Course Title
Instructor
(i.e. College Algebra)
(i.e. Smith)
1
2
3
4
What is your status in the class?
On Track
A little behind
Failing the class
On Track
A little behind
Failing the class
On Track
A little behind
Failing the class
On Track
A little behind
Failing the class
Please complete the following assessment:
How much time do you devote each day to studying?
2 hours or more
1 to 2 hours
Less than 1 hour
How often are you prepared to meet with a tutor?
2 times a week
1 time a week
Only as needed
Would you attend a Study Skills Workshop offered at Academic Skills Center?
Why are you seeking tutoring? Leave any comments for your tutor here.
Would you like your tutor to help with
a. Recognizing Learning Style
b. Improving study habits
c. Improving time management
Yes
Yes
Yes
Yes
No
No
No
No
Maybe
Check here if you need more space and leave additional comments on back.
Read and initial the following statement before signing and submitting this tutor request form.
______ I understand that if I have not received an email within a few days, it is my responsibility to contact the Academic Skills Center regarding the
status of my request. I will make every effort to adjust my schedule so that I may meet regularly with my tutor and if my assigned tutor sees that I am
not committed by cancelling or not showing up to at least two scheduled sessions, I will be notified by email that all future tutoring sessions may be
cancelled. , I will arrive to the tutoring session on time and prepared, bringing my textbook and having attempted any homework assignments on my
own. I will not expect my tutor to complete homework assignments, online quizzes and tests, or other assigned work for me. If I have any problems
with my assigned tutor, I will contact the Academic Staff Assistant immediately. If I cannot obtain satisfactory resolution with the Academic Staff
Assistant, I may notify the Academic Skills Center Director, or the Director of Disability Services and Testing.
Signature
Date
Office Use Only
Date
Comments
Form updated 3/5/12