Student Name
Student ID Number
Winter 2023 Spring/Summer 2023 Fall 2023
Faculty/Staff Information:
Faculty/Staff Name
Faculty/Staff E-mail
Is this concern related to a specific course? Yes No
If yes, please enter the course.
Student Concerns:
Excessive Absences
Unprepared
Need Reading/Writing skills
Failed Exam
Missed Assignments
Other
The U of R collects information under authority of The University of Regina Act in accordance with the Local Authority Freedom of Information & Protection of Privacy Act and the Personal Information Protection & Electronic Documents Act for purposes of enrolment, academic status, and administration of programs/services. By responding to this form, you consent to the use your personal information to communicate with you regarding Student Success Centre initiatives.
