ASC Intake Form

Academic Success Center Intake Form

Use this form if it is your first time requesting services from the Academic Success Center. You only need to complete this form one time. If you are already in contact with the ASC, please use our email address, asc@gordon.edu or call X4743.

1. Full Name (First and Last required):

2. Gordon Student ID #

3. Date of Birth - enter a date in month/day/year format (xx/xx/xxxx)

4. Email Address:

5. Cell phone number:

6. What is your class year at Gordon?

7. Do you live on campus?

	Yes
	No

8. If you live on campus, which residence hall do you live in?

9. If you live off campus, what town do you live in?

10. What is your home state or country?

11. Do you want to disclose a disability? If so, what is the nature of your disability?

12. What are your reasons for contacting Academic Support? Please check all that apply.

	Referred by a professor
	I think I may have a learning disability
	I'm struggling in a class(es)
	ELL/ESL issues
	I am experiencing emotional issues that are affecting my academics
	I need study skills and/or time management help
	Other

13. Are you an English Language Learner?

	Yes
	No

14. What is the best way to reach you, email or phone? Please leave email address or cell phone number below.

Leave this blank
Do not change this

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Gordon College, 255 Grapevine Road, Wenham, MA 01984
978 927 2300 | admissions@gordon.edu | info@gordon.edu

Gordon College is one of the nation's premier Christian colleges and located just north of Boston. We offer students extraordinary access to leading-edge opportunities for intellectual, professional, and leadership development to address the increasingly complex challenges of a global society. Gordon stands apart from other outstanding institutions in New England by combining an exceptional education with an informed Christian faith.