Project Mentor Request Form
Student Name: ___________ ______ SSN: ___________
(Please Print)
Phone Number: ___________ ______ Email: ___________
Cell Number:
____ Spring semester ____ Summer semester ____ Fall semester____ 20
Subject(s) with which you will need assistance:
Would you like to request a specific tutor:
Please indicate how many hours per week by checking one of the following:
_____1 hour per week ($225.00 per semester)*____ _____4 hours per week ($900.00 per semester)
_____2 hours per week ($450.00 per semester)____ _____5 hours per week ($1,125.00 per semester)
_____3 hours per week ($675.00 per semester)____ _____6 hours per week ($1,350.00 per semester)
* 1 hour per week must be approved by LD Coordinator
Responsible Party (Check one):________ Parent ____ VRC ____ Other
Name of VRC (if applicable): ____
_______ ______
Signature of Student Date
_______ ______
Signature of Responsible Party Date
NOTE:
Failure
to meet with your assigned mentor will not result in a refund for unused
hours. If the Department of Vocational
Rehabilitation provides assistance, failure to use the requested hours could
affect the amount of mentoring authorized for subsequent semesters.
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Office use only:
Tutor(s) Assigned:
Date Assigned:
Date Billed: Amount Billed: