LSC Student Cohort Request Form

Click on "Submit" button at bottom of form when done.
Date of request

Requestor’s Name

Requestor’s Email

Contact Phone #

Course & Section numbers requested:

Report Frequency:
Only once (Priod start date to end date )
Weekly (Start date to end date )
Bi-weekly (Start date to end date )
Monthly (Start date to end date )
Other

Delivery of Report:
Email address to send the report to:
Intercampus
Other:

*Submit will send the information typed above via email to the LSC Director, LSC Coordinator, and Office Coordinator. Submissions need to include the information requested above in the form.
*Reset will blank out and lose all information typed above.