Student Success Academic Coach Application
Name
First Name
Last Name
ID Number
Email
example@example.com
Year
Freshmen
Sophomore
Junior
Senior
Current GPA:
Home/Summer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
University Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Advisor
Major
Minor
Do you qualify for work study employment?
yes
no
Have you ever held or are you currently holding a job on campus? If yes, please describe your duties:
The supervisor for your on campus job was/is:
If you are currently working anywhere, how many hours do you work per week?
Briefly describe what you see as the role and purpose of an academic coach:
Why are you interested in being an academic coach?
Specify any other time commitments and activities with which you are currently involved (e.g RC., clubs, student government, student ministries, off-campus jobs, sports, etc.) Explain your role or involvement:
How many credit hours do you plan to take next semester?
List your three faculty references here:
Signature
Submit
Should be Empty: