By completing this tutor request form, you are making a commitment to attend all scheduled tutoring sessions throughout the semester. You must complete a tutoring contract with the tutor coordinator prior to tutoring.
Name: ________________________________________ Semester: _____________________
Phone: ________________________ __________________________
Cell Other
MTSU email: __________________ Best way to contact: Email __ Cell __ Other # __
______________________________________________________________________________
Subject: __________________________ Are you repeating the course? Yes ____ No ____
Course Number: _________ Section: ________ Instructor: _____________________________
What is your current grade in this class? A B C D F Unknown
Have you discussed your need for help with the instructor? Yes ____ No ____
If yes, when? ____________________________________
How many hours a week are you studying/working on this class? __________
Have you missed any classes? No ____ Yes ____ If yes, how many? __________
Why do you feel you need tutoring? ________________________________________________
_____________________________________________________________________________
Please read the following carefully and sign below:
I understand that this tutor request form is for active TRIO SSS members only. I understand I must meet with the tutor coordinator before tutoring can begin. I understand that I am responsible for reporting to every scheduled tutoring session on time. If I am unable to attend, I will notify the SSS Office to cancel at least 24 hours prior to my scheduled session. If I miss multiple sessions although I provided 24 hours notice, it is my responsibility to schedule an appointment to meet with the tutor coordinator to discuss tutoring for the remainder of the semester. I understand that if I miss two or more tutoring sessions without 24 hours notice, I may forfeit the opportunity to be tutored for the remainder of the semester.
Signature :_____________________________________________ Date :_____________
See other side for availability
FOR OFFICE USE ONLY
Tutor Assigned: __________________________________________________
Completed Tutoring Orientation: No: ___ Yes: ___ If yes, date: _____ Coordinator initials: _____
Staff Comments: ______________________________________________________________________
Updated 8/2015

List your best availability for tutoring: For example, MWF 8-10 am
1 st
Choice: ______________________________
2 nd Choice: ______________________________
3 rd
Choice: ______________________________
Please cross out times when you are not available:
Hours
8:00 a.m.
8:30 a.m.
9:00 a.m.
9:30 a.m.
10:00 a.m.
10:30 a.m.
11:00 a.m.
11:30 a.m.
Monday
12:00 p.m.
12:30 p.m.
1:00 p.m.
1:30 p.m.
2:00 p.m.
2:30 p.m.
3:00 pm.
3:30 pm.
4:00 p.m.
Tuesday Wednesday Thursday
SSS staff will consider any and all available times you put down. However, there
Friday is no guarantee you will be scheduled during your optimum time as staff must review tutor availability as well.