Student Success Coach Request Form
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1. Coaching Form

Thank you for your interest in Student Success Coaching! Please fill out the following information and your new coach will contact you soon:

1. Please fill out the following questions about yourself:

Please fill out the following questions about yourself: Name:
Student ID or Birth date:
Email Address:
Phone Number:
What is the best way to reach you (phone or email)?
When is the best time to reach you?

2. Please check all the hours you are available to meet with a coach:

	Monday	Tuesday	Wednesday	Thursday	Friday
9:00	*Please check all the hours you are available to meet with a coach: 9:00 Monday	9:00 Tuesday	9:00 Wednesday	9:00 Thursday	9:00 Friday
10:00	10:00 Monday	10:00 Tuesday	10:00 Wednesday	10:00 Thursday	10:00 Friday
11:00	11:00 Monday	11:00 Tuesday	11:00 Wednesday	11:00 Thursday	11:00 Friday
12:00	12:00 Monday	12:00 Tuesday	12:00 Wednesday	12:00 Thursday	12:00 Friday
2:00	2:00 Monday	2:00 Tuesday	2:00 Wednesday	2:00 Thursday	2:00 Friday
3:00	3:00 Monday	3:00 Tuesday	3:00 Wednesday	3:00 Thursday	3:00 Friday
4:00	4:00 Monday	4:00 Tuesday	4:00 Wednesday	4:00 Thursday	4:00 Friday
5:00	5:00 Monday	5:00 Tuesday	5:00 Wednesday	5:00 Thursday	5:00 Friday
6:00	6:00 Monday	6:00 Tuesday	6:00 Wednesday	6:00 Thursday	6:00 Friday

3. When and where did you complete your last school experience?

When and where did you complete your last school experience?

4. Do you know what you want to major in at Edison College? If yes, please specify which major.

Do you know what you want to major in at Edison College? If yes, please specify which major.

5. Are you working in a job while attending classes at Edison? If yes, how many hours do you work?

Are you working in a job while attending classes at Edison? If yes, how many hours do you work?

6. What are your three main concerns that could prevent you from succeeding in school?

What are your three main concerns that could prevent you from succeeding in school? 1.
2.
3.

7. In what areas can we help you succeed with your college goals?

In what areas can we help you succeed with your college goals? Time Management

Test Taking

Test Anxiety

Selecting a Major

Note Taking

Procrastination

Fear of Math

Memory Skills

Computer Skills

Other (please specify)

Thank you for your interest! Please press "done" to complete the survey and your coach will contact you soon!

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