NMC Tutoring Services

Application to Receive Tutorial Services

Date of Application:

Phone Number:

Name:

SS#/Student ID:

Requesting Tutoring for which Class(es)?		Instructor(s):

Did you receive tutoring last semester? Yes. No.

Briefly describe your academic problem:

Have you discussed this with your instructor? Yes. No.

What are your current test scores?

Demographics — Check all that apply:

Documented disabled	Displaced Homemaker (primary home maker/now entering the work force)
Single parent/unmarried pregnant woman	Limited English Proficient (English is 2nd language)

Who referred you to the Tutoring Program?

What are your Financial resources for tuition at NMC—Mark all that apply:

Pell Grant	Employer	Michigan Works	Voc. Rehab.
Parents	Self	Scholarship	Loan
Veteran (GI Bill)		TIP (Tuition Incentive Program)

If you receive JobNet or Voc Rehab resources, who is your counselor?

Who is your academic advisor/counselor?

What are your career plans?

Have you reviewed your academic plan with a counselor/advisor? Yes. No.

If no, would you like someone from the NMC Career and Employment Services Office
to contact you for career exploration? Yes. No.

Student Contract

I understand that if I accumulate two cancellations or absences, my standing with the tutoring program will be re-evaluated and/or my tutoring sessions may be cancelled.

Authorization for Release of Information

I understand that the Tutorial Coordinator will have access to my NMC transcripts and placement scores to evaluate what services may be necessary. I understand that the Tutorial Coordinator will discuss any academic problems that I have with my tutor in order to improve my tutorial experience.

Student Signature:

Date: