RHS Staff Referral

Staff, Please complete the following to refer a student to the
TRHS NHS Peer Tutoring Program.
** Students will need to complete a Student Availability Form if the student information at the bottom is not provided by you.
We will let you know if/when a tutor is available for your student.
Any assistance you can give the student to help guide the tutoring process, such as worksheets, specific problems, is very appreciated.

Staff Member's Name *

Staff Member's Email *

Student's Name *

First

Last

Student is aware of referral *

Yes None

Student Motivation Level *

Grade *

9th 10th 11th 12th

Subject in which assistance is needed *

Specific Concerns/ suggested # of periods/week to meet *

Student Information, if available. All information is needed to schedule.
Student can complete this at his/her convenience by going to the "Student Availability Form."

Student Email *

Student Phone Number *

Student can receive/send text messages on this number *

Yes No

Please list student's availability (period number, before or after school) *

Submit