Title III Student Self-Report Form (Sample): DATE: 02/16/05 Which Course(s) does this report affect? (Hold Down CTRL key to select more than one course if needed) None MAT-0024 REA-0002 ENC-0010 SLS-1990   Student: John Doe Email: * Phone: * Note: Completing this form does not excuse you from any required class, activity, or assignment but offers you a way to share important information. Comment(s)/Request(s) by student: FYI: I will miss class on January February March April May June July August September October November December/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31/ 2004 2005 2006 2007 2008 2009 2010 2011 2012 calendar FYI: I will miss class on January February March April May June July August September October November December/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31/ 2004 2005 2006 2007 2008 2009 2010 2011 2012 calendar  I would like to request a counselor/advisor meeting  I would like to request a meeting with my instructor  I would like help with my educational plan  I would like to request a meeting with all my instructors  FYI: I need to drop this class  I would like information on additional resources  Other:   Additional information regarding above comment(s)/requests: Please complete this part with any information such as particular dates, times, or other information that may better help the counselor/advisor, instructor, and/or staff understand your comment or request. Thank you! Click on the appropriate people who should receive this information:  the instructor(s) of the classes  my counselor/advisor