ACADEMIC COACHING REQUEST FORM 

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ACADEMIC COACHING
REQUEST FORM
NAME:
KU ID:
MAJOR:
PHONE:
KU EMAIL ADDRESS:
@live.kutztown.edu
Please indicate if you belong to any of the following groups:



STUDENT SUPPORT SERVICES / TRIO (SSS)

UNDER A 2.25 GPA
DISABILITY SERVICES OFFICE (DSO)
ATHLETICS
What is an Academic Coach?
Academic Coaches are undergraduate students who help their peers succeed! They differ from tutors, which give
supplemental information for a specific course, in that academic coaches work with student to improve their overall study
skills such as note taking, time management, test taking, critical thinking, presentation skills and more!
Area of Need (please check all that apply)
 Critical Thinking
 Textbook Reading
 Presentation Skills
 Time Management
 Healthy Living
 Study Techniques
 Test Taking
 Stress Management
 Note Taking
 Lecture Class Success
 Research Paper Skills
 Other: _______________
OFFICE USE ONLY 
•
MATCH:
DATE:
All of this information can be located on your class syllabus and in your MyKU account.
• If any of this information is missing, it will delay processing of your request until you provide us
with complete information.
TUTORING SERVICES HAS PERMISSION TO RELEASE MY NAME
TO MY PROFESSORS AND/OR ADVISOR:
Signature:

YES

NO
Date:
ACADEMIC ENRICHMENT & TUTORING SERVICES | ROHRBACH LIBRARY 30 | (610) 683-4207 | [email protected]
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