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EKU
Eastern Kentucky University
Student Success
Student Support Referral Form
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This form is to be completed for online students only
Your First Name
Your Last Name
Your Email
Student's First Name
Student's Last Name
EKU ID -
Optional, but helpful.
Email -
If you don't know the student's EKU ID number, please include their email address.
Please describe your connection with the student:
Please describe your connection with the student:
Instructor/Facilitator
Academic Advisor
Tutor/Consultant/Mentor
Peer
Family/Friend
Class
Academic challenges
(check all that apply)
:
Academic challenges
(check all that apply)
:
Poor or incomplete assignments
Poor performance on quizzes or tests
Lack of content understanding
Exhibits low level of participation
No class participation
Other
Details of Other Academic Challenges:
Other Issues:
Other Issues:
Family/Personal
Financial
Involvement
Other
Details of Other Issues:
Please include additional notes regarding the student:
Submit
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Eastern Kentucky University
521 Lancaster Ave.
Whitlock Building
Richmond, KY 40475
Phone: 859-622-1000
eku.edu
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