Name of Student Being Referred: 

Student's ID Number: 
(if known) 

Student's E-mail Address: 

Instructor's Name: 

Course: 

Instructor's E-mail Address: 

Instructor's Phone: 

Reason(s) For Referral: 
(Check all  that apply) 

Comments: 
(optional) 

Thank you for providing this information. Upon selecting the "Submit" button, the information will be emailed to:

Scott Amundsen, Director, Office of Academic Advising & Retention, 859-622-2276, scott.amundsen@eku.edu.

You will receive a confirmation shortly via e-mail.