Student Tutoring Request Form

Name:

Date:

Home Phone Number:

Cell Phone Number:

Email:

Major:

Advisor:

School:

Women's College	Continuing Education	Graduate
SOC	International/ESL	CAPS
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For which course would you like tutoring?

Course Number:

Course Title:

Instructor:

Type of tutoring assistance you require?

Do you need regular (weekly) tutoring?

Do you need short-term assistance with a specific assignment?

1. I assume sole responsibility for my final grade.
2. I understand that tutoring does not guarantee a passing grade; hard work on my part in conjunction with totring will promote progress in a given course.
3. I will make note of my tutor's name and phone number.
4. I will show respect for my tutor at all times regardless of my current grade in or opinion of the course.
5. I will attempt to complete all assignments and attend all classes.
6. I will contact the tutor 24 HOURS in advance if I am unable to attend a schedule tutoring session.
7. I will come to each session prepared, bringing texts, syllabi, assignment sheets, notes, and questions.
8. I understand that missing two tutoring sessions without notifying the tutor 24 HOURS in advance will result in the loss of my tutoring privileges for the current semester. in the event that I am not responsible enough to come to scheduled tutoring sessions, the only tutoring I will be permitted to attend will be open "walk-in" tutorials where I will have to wait my turn for tutoring.
9. I will contact the Director or Assistant Director of the Conklin Academic Skills Center if I have any concerns about my tutor.
10. I understand that failure to comply with these conditions will result in the loss of my tutoring priveleges.

Statement of Contract Agreement

By submitting my request form, I agree to the requirements and conditions for receiving tutoring services as posted at the Conklin ASC. I understand that failure to fulfill the requirements and conditions may result in my forfeiting my tutoring privileges.