Tutor Name
Home Phone
E-mail
Student Name
Home Phone
E-mail

Has there been a change of address or phone number?

Tutor change       

Student change   

Best time to contact tutor      

Best time to contact student  

Hours spent working with      
partner (include telephone 
lessons, field trips, etc.)

Tutor hours spent                  
in preparation   

Are you currently meeting ? Yes No If not, why?

Is this permanent ? Yes No
If no, when will you resume?  

Are you available to tutor someone else ? Yes No
If yes, days and hours (mornings, afternoon, evenings)  

Does your partner have children under age 10? Yes No
Birth year and sex for each child:

Partner's Achievements (check all that apply - some items, such as "Improve basic skills" may apply in more than one quarter)

For B and C, specify new employer

For H, I, J, N, and O specify school / program

For L, P, Q, and R, specify the achievement or addition

Partner would like information about Adult Education? Yes No

Student's Name:

TO BE COMPLETED BY TUTOR

I feel my student is making progress toward his/her goals.
Strongly Agree
Agree
Disagree

The biggest problem I am having as a tutor is:


I would like information concerning:


I would be interested in workshops or newsletter articles concerning:


I wish there had been more focus in tutor training about:


I would like to help MLP in other ways.
Yes
Not at this time.

I would like to speak with a member of the MLP staff:
Yes
No
I have taken part in the following tutor development activities:
(include date, number of hours and brief description.)

Comments:

TO BE COMPLETED BY STUDENT (TUTOR MAY ASSIST)

I feel I am making progress toward my goals.
Strongly agree
Agree
Disagree

The biggest problem I am having as a student is:

I would like information about Adult Education/ESL programs:
Yes
No

I would like information concerning:

I would be interested in helping MLP as a student volunteer:
With mailings
With newsletter
Talking to new tutors
Let me know about other things that you are doing

I would like to speak with a member of the MLP staff:
Yes
No

Comments: