STUDENT INFORMATION SURVEY/REGISTRATION FORM

University Tutorial Center
California State University, Los Angeles

Your information will be kept secure and confidential.

Please complete this form in order to access the Moodle course University Tutorial Center Online. You will be sent an email with an enrollment key to allow you to self-enroll for this course once you have completed the form.

1. Contact Information *This question is required.

First Name

Last Name

CSULA Email Address

Phone Number

2. CIN: *This question is required. This question requires a valid number format.

3. Date: *This question is required.

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The following information is used for STATISTICAL PURPOSES ONLY.

4. Gender:

5. Is English your primary language spoken?:

6. Are you an Educational Opportunity Program (EOP) student?:

9. Major:

STUDENT INFORMATION SURVEY/REGISTRATION FORM

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