CC - Learning Center Request

Learning Center Request
City College has established a Learning Center to address the needs of students requiring academic assistance or remediation in their efforts to achieve and maintain satisfactory academic progress. The Learning Center is staffed with faculty members who are available to assist students with their academic needs. If a faculty member feels that a student needs additional assistance outside the scope of the Learning Center, they may recommend that the student seek additional tutorial services beyond those provided by the Learning Center Students who wish to utilize the Learning Center must register at least one week prior to the requested date, by completing this form.
Student Name:*

First NameLast Name
E-mail Address:*
Phone Number*

Area CodePhone Number
Campus:*
Program Name:*
Program Chair Name:*

First NameLast Name
Program Chair Email Address:*
example@example.com
Program Start Date:*
Month and Year student started program.
I need assistance from a:*

InstructorPeer Tutor (a fellow student)
I need assistance with:

Writing Structures & APAReading ComprehensionStudy StrategiesLab SkillsCore Class/Lecture TopicsOther
Number and Name of course needing assistance with:*
Topic/Session needing assistance with:*
I would like to be scheduled for lab skills on the following date: *

MonthDayYear
Specialty/Skill Needing Assistance With: *
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Please be sure to use your FULL SIGNATURE when signing documents.
Student's Signature*

Clear
Full Name of Signer

First NameLast Name
Enter the message as it's shown*

Administrative Office Use Only
Date Schedules for LC
Program Chair's Signature
Date:
Should be Empty: