SSC: Student Referral Form

Fill out the following webform if you have a concern about a student regarding academic success, attendance, financial aid, etc. This information will go to the Director of the Student Success Center for response. Please put as much information as possible in the referral.

In cases where the student is a danger to her/himself or others, please contact the EKU Police Department immediately (phone: 859-622-1111). Please note that the SAIT form should be used to report students who appear to be troubled or troubling to elicit a response from University officials before the student's behavior reaches a crisis level.

Information of Student to be Referred

First Name

Last Name

Preferred Name

Student's EKU ID Number

If you don't know the student's EKU ID number, please enter their EKU email address.

Student's EKU Email Address

Submitter Information

Your First Name

Your Last Name

Your Email Address:

Please describe your connection with the student:

Would you like to remain anonymous?

Yes

Student Academic Challenges (Select all that apply):

Is the student at risk of leaving EKU?

Yes

Maybe

Please include other information that you believe is important for us to know about the student.

SSC: Student Referral Form

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