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Learning Services Center
Massachusetts College of Liberal Arts
Learning Services Center TUTORIAL REQUEST FORM
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TUTEE CONTRACT WITH LEARNING SERVICES Please Print Student Name:____________________________*Gender: F___ M___ SS#_________________ Home Address:____________________________________________________ Campus Box #_______ College/Cell Phone # ____________Year of Grad _____ Major _____ Email address______________________ Course Name ____________________________ Course #______________ Instructor _____________________ What grade do you feel you would receive without this tutorial?_______ *Date of Birth __________ Does your mother have a BA/BS degree? _____Yes _____No Does your father have a BA/BS degree? _____Yes _____No *Do you have a disability? _____Yes _____No If yes, is documentation of this disability on file in the Learning Services Center? ____Yes ____No *Ethnic Identity _____American Indian _____Cape Verdean Hispanic/Latino _____Bi-racial _____Asian/Pacific Islander Black/African-American _____White/Caucasian It is assumed (agreed) that students requesting a tutorial have discussed their situation with their faculty member. If a course has a TA (teaching assistant), students need to work with that individual instead of requesting a tutor. Students are responsible for attending all arranged tutorials. Should extenuating circumstances necessitate absence, students must notify tutors prior to the tutorial session. *3 unexcused absences would lead to dismissal from the tutorial group. I, the undersigned, agree to the terms stipulated by the Learning Services Center/Tutor Exchange Network. Student Signature_________________________________ Date:____________ * Information on gender,age, ethnic origin and disability is optional. It is collected for compliance reports in connection with federal regulations pursuant to the Civil Rights Act of 1964, Executive Order 11246 as amended by the Executive Order 11375, and Title IX of the Education Amendments of 1972 and Part 86.45 C.F.R. This is a voluntary action to overcome effects of limited participation. Information will be kept confidential. Refusal to furnish such information will not be used to discriminate in admission or particiption in any of the educational programs or activities offered at Massachusetts College of Liberal Arts. ____________________________________________________________________________
BELOW THIS LINE FOR OFFICE USE ONLY Tutor Assigned________________________Placement Date__________ Fam.______ Inco.________ Elig.______ Y B Code___________ For comments or questions, contact claire.smith@mcla.edu or d.poulton@mcla.edu MCLA -- 375 Church Street, North Adams, MA, 01247-4100 -- (413)662-5314 fax (413)662-5319
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