Name of Primary Contact: CCRI Student ID #:
Home Phone #: Work Phone #:
E-mail address:

Course you're requesting to set up a study group for:
Instructor:

Please choose your campus:

Select One Lincoln (Flanagan) Campus Providence (Liston) Campus Warwick (Knight) Campus

I was referred to the Success Center by:

Self            Friend         Instructor         Other

Do you have other students ready to join your group?
Yes   No

If so, list names: