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Referral Form

Please use this form to refer a student to us who is not making normal progress (i.e., may not finish the semester with a grade of C if the present pattern continues).

Student's Name
Course number or how I know student
Reasons for reporting	Poor test scores Failure to do assignments Assignments inadequately completed Class participation Frequent absences Health problems Personal problems Other (explain in additional notes) Unknown
Additional Notes	Please be as specific as possible.
Faculty/Staff Name
Faculty/Staff Email
Don't forget to submit when you are finished!