Franklin University Request for Tutorial Services Form

Name:
Address:
City:
State:
Zip Code:
Social Security #:
Home Phone:
Work Phone:
Fax Number:
E-Mail Address:
Please note: If you are using your Franklin University student e-mail address, it must end with "@email.franklin.edu" not "@franklin.edu".
Your major:

Course:
Instructor:
Course Format:
Location:
Course Start Date:	// (mm/dd/yyyy)
Class Status:

What gives you the most trouble in this course?:
(select all that apply)

	Reading the textbook
	Understanding the lectures
	Doing the homework
	Taking the tests
	Other (please explain below)

If other, please explain:

Have you visited the bulletin board?

Have you visited the chat room?

Have you visited the instructor during office hours?

Read the agreement below:

I understand that I may be interviewed by a staff member of the TLC before being assigned an individual tutor. As a recipient of tutoring services, I have read the responsibilities document. The TLC also has my permission to contact the instructor of this class.

Check if you agree to the above.

Which type of tutoring are you requesting?
	Asynchronous (If checked, answer the next question, and skip the shaded area below.)
	Synchronous, you and the tutor need to schedule tutoring times. (If checked, skip the next question, and complete the shaded area below.)
Asynchronous
For asynchronous tutoring, there will be a maximum two-business-day turnaround time. Which method of communication do you prefer?
	Bulletin Board System
	Fax

Additional Comments:

Read the agreement below:

Asynchronous

Synchronous