GGAC Peer Tutoring Program APPLICATION FORM

Please complete the following in the spaces provided:

I. Biographical Information:

Name:

Address:

Phone number:

Email:

Date of Birth: M/D/Y

Social Insurance #:

Have you been paid by Queen’s before? Yes ___ or No ___

If yes, when and by which department? ____________

If no, you must supply a void check.

II. Academic Information:

Student Number:

Academic Program:

Current Year of Study:

Courses you are Interested in Tutoring:

Please list here and provide grade received in the course

Subject Grade Received

1.

2.

3.

How often would you be available to tutor? Please provide an estimate of the number of days and hours per week.

II. Athletic Profile:

Team:

Currently a member:

Coaches Recommendation: Please provide in the space below:

DATE: (M/D/Y) COACH’S SIGNITURE:

By signing this form, I am aware of the following expectations and conditions for employment:

1. That I will comply with the Queen’s University Harassment/Discrimination Policy, which provides safeguards and complaint procedures for all of its members against any form of harassment or discrimination. These include harassment and discrimination on the basis of race, ancestry, place of origin, colour ethnic origin, citizenship, creed, sex, sexual orientation, age, marital status, family status, and handicap.

2. I am currently enrolled as a student at Queen’s University and belong to an interuniversity or university club team.

3. I have successfully completed or am currently enrolled in the course I intend to tutor.

4. I acknowledge that the tutoring sessions will not exceed 2 hrs.

5. I understand that the number of tutoring sessions will depend on the individual needs and requirements of the student athlete.

6. I understand that I must contact the student athlete by email within 48hrs upon receiving his/her email address to set up an appropriate time and date.

7. I understand that I must have this tutorial session approved by the Program Coordinator before it takes place.

8. After each session, I will complete the necessary form documenting the session and will hand it in to the program coordinator.

9. If I am unable to fulfill my commitments, I am responsible for contacting and informing the student and program coordinator.

10. I will notify the program coordinator if my status changes and if I am no longer able to continue with the service.

Signature: Date M/D/Y: