Academic Success Program Enrollment Form (FOR STUDENTS) - (FY16)



A red asterisk (*) indicates required questions.


Please enter your Student ID:*


Student Last Name:*


Student First Name:*


Student Advisor Last Name:


Student Advisor First Name:


Campus:  *


Term:  *


Year:  *


With which course is the student having difficulty? {Example: English 101}*


Instructor Last Name:*


Instructor First Name:*


Are you a full-time or part-time student this term?*
Full-Time
Part-Time


What difficulties are you experiencing that affect your performance? (Check all that apply.)*
Class Attendence
Tardiness
Poor Study Habits
Not Sure How to Study
Trouble Staying Focused in Class
Low Test Scores
Reading Problems
Writing Problems
Failure to Turn in Work
Difficulty Understanding Subject
Low Overall Average in the Course
Personal Problems
Anxiety
Worried about Careers
Other


If you selected "Other" above, please explain.


Which of these services do you think could help you succeed? (Check all that apply.)*
Academic Success Coach
Counseling Center
Tutoring Center
Disability Access Accommodations
Academic Advising
Career Planning Other


If you selected "Other" above, please explain.


Have you met one-on-one and discussed these academic difficulties with your instructor?*
Yes
No


Please enter your home phone number:


Please enter your cell phone number:


Please enter your work phone number:


Please enter your school email:


Please enter your personal email:


How would you like to be contacted? (Check all that apply.)*
Phone Call
Email
Text Message


Please provide any additional comments or information here: