Request Form For Individual Sessions

Name:
Course:
Instructor:
Primary Phone:
(xxx-xxx-xxxx)
Alternate Phone:
(xxx-xxx-xxxx)
Harford E-mail:
(student@owlmail.harford.edu)
What is your approximate grade in this course?:
I have worked with my instructor:  Yes   No
I have walked in the center or attended group/supplimental instruction sessions three or more times:  Yes   No
If requesting individual learning assistance, please indicate the reason for your request:
I received below a "C" on a test or quiz
My instructor recommended it
I am repeating the course
Other (Please explain):
Please indicate the times you are available for receiving learning assistance, showing as much time as possible:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
If you have any questions, please contact Diana Pinargotte at 443-412-2427.

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