Date Received: ____

CAM Signature: ___

 

SPECIAL REQUEST FOR TUTORING

 

The Student-Athlete must return this form to the Coordinator for Academic Monitoring twenty-four (24) hours after the

first tutoring session. Please return this form to The Center for Student Success, 3rd floor, Room 318 Hodgin Hall.

Date: _____________________

Student-Athlete's Name: ___________________________________ Classification: ___________________

Sport: ____________________________________________ Telephone : _________________________

Campus Address: ______________________________________________________________________

(Residence Hall, Room Number)

Campus Mailing Address: ________________________________________________________________

Email Address: ________________________________________________________________________

Please indicate below the subject/course name and number for which you are requesting additional tutoring. (If you
are requesting assistance in different subject areas, please complete a form for each subject area. For example, if you
need additional tutoring in Math 101 and ENGL 100, you must complete two separate forms.)

COURSE & COURSE

NUMBER

COURSE NAME

TIME/DAY

INSTRUCTOR
       
       
       

 

I am requesting additional tutoring for the following course(s) listed above. The tutor has identified additional tutorial
services in the subject area in which I need assistance. I understand that it is my responsibility to take advantage of the resources made available to me.

Student-Athlete's Signature: __________________________________ Date: __________________

Tutor's Signature: __________________________________________ Date: __________________

 

To be completed by Department Tutor

Date: ______________________ Length of time spent tutoring:_______________________________________

Will you be giving individual tutoring on a regular basis with Us student-athlete? [ ]Yes, [ ] No

If yes, please indicate the date and time for tutoring _________________________________________________________

Department Tutor's Signature: _____________________________________ Telephone #: ________________________

North Carolina Agricultural & Technical State University

The Center for Student Success

"Empowering Students for Academic Success in the 21st Century"

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