Student Referral Form
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This application should be
returned to:
Academic Initiatives For Mentoring Students
University of North Carolina at Charlotte
318D Fretwell Building
Charlotte, NC 28223-0001
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Staff/Professor Information
Name ____________________________________________________________
Campus Blg/Ofc# ______________________________
Dept. _______________
Phone# ________________________
E-mail
____________________________
Student Information
Full Name __________________________________
SID# ________________
Phone
___________________________ E-mail
__________________________
Major ________________________ Classification
________________________
Type Of Referral
Select type of Referral
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_____ Academic
Advising |
_____ Tutoring |
_____ Other |
Course Information
| Course/Section Number |
Instructor |
Time/Day |
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Student Referral Form. Copyright © 1999 [Academic Initiatives For Mentoring Students]. All rights reserved.
Revised:
September 28, 2004
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