Use this form to request a tutor

1. Tutor Request FormEmpowering. Encouraging. Enlightening.Semester: ______________ Date: _________________Name: __________________________________________Student ID or Social Security Number: _____________________________Cell Phone: __________________________Home Phone: _________________________Primary E-mail Address: __________________________ I need tutoring in: CoursesList Instructor1.2.3.4.5. I am available for tutoring on the following days at the specified time: Monday @Tuesday @Wednesday @Thursday @ Friday @Saturday @Sunday @ Have you received tutoring from the Power Hour program before? YES/NO How did you hear about the Power Hour program? Friend/Professor/Flyer/Orientation/Online/Other: *This Section Office Use Only* *Study Skills Appointment Date: *Potential Tutor Matches: *Tutee Notified of Match by: *Notes: