Student Needs Checklist

To the Student: This form has been developed to help your instructor/advisor get to know you better. Please check any areas, which you feel, may challenge your success in school this semester.

_____ 1. Class attendance

_____ 2. Time to complete homework assignments

_____ 3. Employment schedule (before or after class)

_____ 4. Comfort with program selected

_____ 5. Comfort with course schedule

_____ 6. Basic skills needed for your program

_____ 7. Classroom atmosphere

_____ 8. Budgeting/managing finances/financial aid

_____ 9. Transportation

_____ 10. Having role models in your chosen career

_____ 11. Personal support for career choice

_____ 12. Having relevant work experience

_____ 13. Health of self or family member

_____ 14. Chemical/alcohol use

_____ 15. Pending or current court case

_____ 16. Child care

_____ 17. Parenting skills

_____ 18. Self-esteem/self-confidence

PLAN OF ACTION

___________________________________________________________________________________________

I certify that I have gone over this checklist with my instructor and agree to follow up on the action plan indicated above.

SIGNED_________________________________ DATE__________________________