Tutor Request Application

Name(first last):

SS# (no dashes):

Date (mmddyyyy):

E-mail address:

Phone (no dashes):

Hill College E-mail address:

*Most correspondence will be done through your Hill College email

I am requesting tutoring at:

I am requesting tutoring for:

I need tutoring in the following courses:

Best time for me to receive tutoring is:
Days: Times:

How often do you need tutoring:
Once a week Twice a week

Please answer the following questions, starting with the first box. Continue to the end of the page. When complete, please return the form to Ms. Sellers. Someone will contact you shortly in order to arrange for tutoring. Thank you.

Circle “Yes” or “No” for each of the following statements
I qualified for the Pell Grant or other grant aid this semester:	Yes	No
At least one of my parents graduated from a four-year university:	Yes	No
I have a documented physical or learning disability:	Yes	No
I am currently enrolled at Hill College’s JCC campus:	Yes	No

Circle the type of degree you are currently working towards:
	AA (Associate of Arts)
	AAS (Associate of Applied Science)
	CT (Certificate of Technology)
	CC (Certificate of Completion)
Please indicate your current major:

Circle “Yes” or “No” for each of the following statements:
Are you an international student?	Yes	No