CENTER FOR ACADEMIC RETENTION & ENHANCEMENT

Please complete and return to the COPPS Office of Student Services

Student Information

Name

First Last

Student ID#

Local Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Permanent Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Local Phone Number

Alternate Phone Number

Request for tutoring in the following course(s):

Course Name / Professor

List the course name and professor name

Course Name / Professor

List the course name and professor name

Course Name / Professor

List the course name and professor name

Describe the difficulty you are having with the course (s):*

If other please specify

I will attend tutoring sessions as scheduled.
If I am unable to meet with my tutor, I will cancel a minimum of 24 hours in advance.
I understand that if I miss two sessions without canceling 24 hours in advance, I will not be able to schedule individual tutoring for the remainder of the month.
I understand that if I am over 15 minutes late, I am considered a “no show”.
I agree to complete evaluations of tutoring sessions as requested.
I will come to tutoring sessions prepared with specific questions. I will bring my text and all pertinent materials. I understand my tutor will not do my work for me.

Print Name

Date

By selecting "I Agree" below implies that I have read and understand CARE policy and procedure.