Date:
Semester requesting a tutor for: Select One Fall 2008 Spring 2009
Name: CCRI Student ID #:
Intended Major: Select One Business Administration Engineering and Technology General Studies Allied Health Dental Health Emergency/Disaster Management Nursing Rehabilitative Health Human Services Legal Studies Liberal Arts Science Technical Studies Undecided
Primary Phone #: Secondary Phone #:
CCRI E-mail address (this will be the primary means of contact):
Participating in Access to Opportunity: Yes  No
Course name and section you're requesting help with:
Instructor:

Days and Times you are available to meet with a tutor:

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

How many credits have you completed?
How many credits are you taking currently?

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

Do you work?
Full Time  Part Time

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