| *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
|
| |
| SID | |
| PIN | |
