Milwaukee Area Technical College - [Tutoring

Tutoring Online Reporting

Tutoring - Client Reporting Form

THIS INFORMATION IS CONFIDENTIAL AND REQUIRED FOR STATE AND FEDERAL FUNDING. ANSWER ALL QUESTIONS.

Today's Date

Program/Major

On-Line College Course Name/Names

On-Line Adult High School Course Name/Names

Number of credits enrolled this semester

First Name
Last Name
Middle Initial
Street Address

City
State/Province
Zip/Postal Code
Country
Area Code & Work Phone
Area Code & Home Phone
E-mail
Please identify and describe yourself:
Date of Birth
Sex	Male Female
Age
Student ID Number
Ethnic Category
Citizenship
Marital Status
Highest Grade Completed
Work Status at Enrollment
Number in Family
Annual Family Income Range:
Disability? (select one)
Single Parent	yes no
Displaced Homemaker: Clients who are adults and have worked at home without pay to care for the family, who are no longer supported by a relative's income, or whose youngest dependent child will become ineligible for AFDC assistance within two years, and are unemployed or underemployed.	yes no
Are you enrolled in a Non-Traditional occupational area? (Example: A man enrolled in Nursing.)	yes no
Do you have a Limited English Proficiency?	yes no
Are you Academically Disadvantaged? (Generally, below a "C" average?)	yes no
Are you currently Incarcerated?	yes no
Primary Goal at entry (please check only one which is to be completed during the current semester you are enrolled in)
How many on-line courses are you enrolled in?
I am enrolled in	courses.
I am also enrolled in traditional (face to face) classes at MATC.	yes no
I have previously completed an on-line course.	yes no

For Students Enrolled in High School Courses

The number of courses you are enrolled in at your regular high school (During the period you are taking the on-line course.)
To what High School will you be applying your on-line credits for graduation?

For All Students

I am taking internet classes because: (Work or Home Schedule, Convenience, etc.)

please confirm your student ID number

(Please click on the submit button only once.) If your have any questions about the form, please e-mail Tutor@matc.edu

Mailing Address: 700 W. State Street, Milwaukee WI. 53233