Name: Social Security #:
Home Phone #: Work Phone #:
E-mail address:

Study group you're requesting to sign up for:
Instructor:

Please choose your campus:

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

I was referred to the Success Center by:

Self            Friend         Instructor         Other

How many credits do you have completed?

Are you an ESL student?
Yes   No

Do you work?
Full Time  Part Time

Problem Areas (check all that may apply):
I have trouble with the course content.
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 objective tests.
I have trouble taking essay tests.

* Please Print and Submit to Success Center, Campus Coordinator

* When attending your study group session, please bring assignments, textbooks, syllabus, and any other related material.