UNI-CUE TUTORING CENTER
TUTOR INFORMATION SHEET
Name (please print) ____________________________________________ Date ________________________
UNI Student Number ___________________________
Phone Number _____________________________
Address ___________________________________________________________________________________
E-mail Address _____________________________________________________________________________
Student Classification:
 Freshman
 Sophomore
 Junior
 Senior
 Graduate (Masters)
Major ________________________________________ Minor _______________________________________
Gender:
 Female
 Male
Racial Background (optional):  African American
 Asian/Pacific Islander  Hispanic
 American Indian/Alaskan Native
 White
 Other____________
Please note any medical condition we should be made aware of: ______________________________________
Do you have tutoring experience?  Yes  No
If yes, please briefly describe your experience: _________
__________________________________________________________________________________________
Please check the levels which you prefer to tutor:  Elementary  Middle School  High School  Adults
Please check all of the subject areas which you feel you are competent to tutor:
 Reading
 French
 Algebra I
 Trigonometry  Chemistry  ACT Prep
 Language Arts  Spanish
 Algebra II
 Calculus
 Physics
 Social Studies
 Basic Math
 Geometry
 Biology
 Other___________________
Do you speak a foreign language?  Yes  No If Yes, which language? __________________________
Do you feel competent to tutor a student in this language?  Yes  No
Please check the days & times that you are available to tutor:
 Monday
___ 4:00-5:30 pm
___ 4:30-6:00 pm
 Tuesday
___ 4:00-5:30 pm
___ 4:30-6:00 pm
 Wednesday
___ 4:00-5:30 pm
___ 4:30-6:00 pm
 Thursday
___ 4:00-5:30 pm
___ 4:30-6:00 pm
___ 5:00-6:30 pm
___ 5:00-6:30 pm
___ 5:00-6:30 pm
___ 5:00-6:30 pm
___ 5:30-7:00 pm
___ 5:30-7:00 pm
___ 5:30-7:00 pm
___ 5:30-7:00 pm
All adults who work with youth at the UNI-CUE must complete Background Checks prior to working with minors.
We require a copy of the Background Check confirmation for our files. If you have not had a background check
completed by the College of Education, UNI-CUE will cover the cost of the background check. Please check the
appropriate box below:
 Yes, I have had a Background Check and can provide documentation, and I will provide a copy of the Background

Check confirmation.
If Yes, please provide the date the check was completed:________________________________________
 No I have not had a Background Check at UNI.

If No, please complete the Authorization for Release of Child Abuse Information. The University will cover the
cost of the Background Check.