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Upward Bound Tutor Application

*Name: 
*SSN: 
*Year:
*Address: 
Apt # : 
*City: 
*State:
*Zip Code: 
*Email: 
*Phone: 
Voice mail (on campus): 
Cell Phone: 
*Major:
Minor:
G.P.A.: 
ACT: 
Emergency Contact
*Name: 
*Relationship: 
*Phone: 
Please check the areas you are qualified to tutor...

Math
Consumer / Basic Math
Algebra
Geometry
Calculus
Trigonometry
Math Analysis

Science
Earth Science
Biology
Zoology
Botany
Anatomy & Physiology
Microbiology
Chemistry
Physics

Social Sciences
Civics
U.S. History
Government
Constitutional Law
World History
Psychology
Sociology

English
English (usage & mechanics)
English Comp
English Literature
World Literature
Speech / Debate

Foreign Languages
Spanish
French
German
Latin
Other
Please List Availability


Please list the times you would be available to tutor on the following days. (Include any evenings)
Monday 
Tuesday 
Wednesday 
Thursday 
Please list any previous experience you may have. Please include experience such as tutoring, working with youth, or other applicable work experience.
 
Please list any extra-curricular activities, additional employment, etc. that you have time obligations to. Please list details such as days, times, special functions, etc.
 
Do you have any conditions which
would require accommodation in
order to perform tutoring services?
Do you hold a valid driver's license?
Please List Two References
*Name: 
*Title / Position: 
*Address: 
*Phone: 
*Company or Institution: 

*Name: 
*Title / Position: 
*Address: 
*Phone: 
*Company or Institution: 


I hereby attest that the above listed information is true and accurate to the best of my knowledge. I understand that if I am employed, that any information withheld, either knowingly or fraudulently represented, could result in disciplinary action or termination as a tutor from the MSSU Upward Bound program.

For MSSU Upward Bound Office Use Only
New Applicant:________ Returning Tutor:________
Interviewed By:___________________Date:______________
Hired:_____Rehired:_____Alternate:_____Non-Hire:_____
Referred to L.C. _______Y _______N
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