Disability & Learning Support Service
Application form for Academic Tuition 2012
Student Information
Name
Student
Number
E-mail address
Mobile number
Date of
application
Date tuition
required
Tuition
What Module are you requesting Tuition in?
Module
Code
Module Title
No. of hrs
Required
Particular Area of Difficulty
Students seeking Maths tuition should go to the Maths Learning Centre, DLSS
has a number of 1 to 1 Sessions available for registered Students
Is the Tuition being sought as an aid to revision for Exams?
Yes / No
Academic Profile (To be completed by Lecturer/Course Coordinator)
Is student attending lectures?
Yes

No 
Is student attending tutorials?
Yes

No 
Is student meeting deadlines?
Yes

No 
Is student progressing academically?
Yes

No 
What areas of additional tuition would be of benefit to this student?
___________________________________________________________
Have you met with student to discuss academic difficulties?
Yes
 No 
Comments and specific module(s) for additional tuition recommended:
Signature of lecturer/ programme chair: __________________________________
Date: _______________
Previous Tuition
Have you already received tuition this Semester form the DLSS?
Yes / No
If so, which subject(s) and how many hours did you receive?
Did you receive tuition last Semester form the DLSS?
Yes / No
If so, which subject(s) and how many hours did you receive?
Are you requesting tuition in a subject that you previously received tuition?
Yes / No
If so, which subject(s) and how many hours did you receive? Also please outline the
reasons you require further tuition
Student Declaration
The information on this application form has been provided in good faith and to the best
of my knowledge it is accurate.
I/we understand that the information that has been provided will be treated
confidentially and that am not bound to accept any of the tuition that may be
subsequently offered.
………………………………………………………………………..
Student signature
For DLLS STAFF
Tuition approved
Yes/ No
Number of Hours
Other Comments
___