Academic Success Program Enrollment Form (FOR STUDENTS) - 2018-2021

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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.)*

Please provide any additional comments or information here: