REQUEST FOR ACADEMIC SERVICES
Leasure Hall Tutoring
201 Leasure Hall
Kansas State University
Manhattan, KS 66506
785-532-5703
Academic Assistance Center
101 Holton Hall
Kansas State University
Manhattan, KS 66506
785-532-6492
Educational Supportive Services
201 Holton Hall
Kansas State University
Manhattan, KS 66506
785-532-5642
PLEASE PRINT CLEARLY
Date: _______________
Name: _______________________________________________________
Last
First
MI
______________________________________________________
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WID
KSU Email Address
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Alternative Email Address
Phone
Major:____________________________
FR
SO
JR
SR
OTHER__________ Last Semester GPA:_______
(Circle One)
Have either of your parents/guardians received a four year college degree?
Yes____ No____
Are you currently receiving any form of financial aid?
Yes____ No____
If yes, please state whether it is a Pell Grant, or work-study:
_______________________________________________________________________________________________
Please rank the preferred method of contact by ESS, 1 is your first choice, 2 is your second choice and 3 is your least preferred method: Text [ ]
Email [ ]
Phone [ ]
Leasure Hall tutoring will contact via email.
List below the courses you need to be tutored in and how many hours per week.
NOTE: The maximum hours per week per subject is 2 hours.
Please indicate Traditional College Algebra as Math 100T and Studio College Algebra as Math 100S
Course # (Example: PHYS 213)
Hours per Week
Preferred Day/Time
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I, ___________________________________, hereby release Educational Supportive Services/Leasure Hall Tutoring Center to
provide information to the staff and faculty at KSU that have a need and a right to know about my academic progress/performance.
______________________________________________________
Student Signature
_________________________
Date
Office Use Only
Classification: EOF_____ ESS_____ ESS Eligibility_____ Academic Need_____ ACT_____ GPA_____ Acceptance Date______________
DON’T FORGET TO FILL OUT THE BACK1
NAME: ______________________________________ Circle Preferred Tutoring Time: Day me Place an “X” in the me slots in which you CANNOT receive tutoring. Open me slots will be considered poten al tutoring mes. HOUR MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 7:3O‐8:20 8:30‐9:20 9:30‐10:20 10:30‐11:20 11:30‐12:20 12:30‐1:20 1:30‐2:20 2:30‐3:20 3:30‐4:20 4:30‐5:20 Evening tutoring available in select subjects: SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY 5:30‐6:20 pm 6:30‐7:20 pm 7:30‐8:20 pm 8:30‐9:20 pm Turn this completed form into 101 or 201 Holton Hall, 201 Leasure Hall or 309 Lafene. If a tutor is available at your indicated mes, you will be no fied by email as to the me and loca on of your tutoring session. If a tutor is not available, you will be no fied by email as well. Evening