Date:
Semester requesting a tutor for: Select One Fall 2009 Spring 2010
Full Name: CCRI Student ID #:
CCRI E-mail address (this will be the primary means of contact):
Intended Major: Select One Administrative Office Technology Biotechnology Business Administration Chemistry Computer Studies & Information Processing Engineering and Technology Fine Arts General Studies Health Sciences Human Services Legal Studies Liberal Arts Science Technical Studies Undecided
Primary Phone #: Secondary Phone #:

Participating in Access to Opportunity: Yes No

Participating in Varsity Athletics: Yes No
Course name and section you're requesting help with:
Instructor:

Days and Times you are available to meet with a tutor: (Example 8-9am,12-3pm)

Monday

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Please choose your campus:

Select One Lincoln (Flanagan) Campus Providence (Liston) Campus Warwick (Knight) Campus Newport Campus

Please select an alternate campus you would like to receive tutoring:

Select One Lincoln (Flanagan) Campus Providence (Liston) Campus Warwick (Knight) Campus Newport Campus

I was referred to the Success Center for tutoring by:

Self            Friend         Instructor        Advisor         Other

Are you an ESL - English as a Second Language -  student?
Yes   No

Problem Areas (check all that may apply):
I have trouble understanding the textbook.
I have trouble managing time.
I have trouble taking notes in class.
I have trouble taking notes from the textbook.
I have trouble taking multiple choice or true/false tests.
I have trouble taking essay tests.
I have trouble with course content.
Please identify the content that you are having difficulty with:

Have you spoken or communicated with your instructor about the difficulties you have had?
Yes  No

Is this the first time you had taken this course?  Yes  No

On average, how much time do you spend studying or doing homework for this course?
0-3 hours/wk  4-6 hours/wk  7-9 hours/wk  10+ hours/wk