Date: 

First Name: Last Name:

Address:

Home Phone:              Work Phone:

Student ID Number:

Please fill in circles corresponding to your answers:

1. Have you sought help from your professor        Yes    No

2. Have you sought help form a learning lab?        Yes     No

3. have you received help at Impact Tutoring in the past? Yes    No

4.  Please identify the primary difficulty with the subject in which you need tutoring:

Need Improved Study Skills Need to Refresh Memory of Subject Lack Good Foundation in Subject

print and return this application to:

Impact Tutoring

Resource Center, Room 105

Takoma Park, MD 20912

(240)567-1557

Or Press Submit