Faculty Information

Student Prescription

To be completed by faculty to refer a student to the ELC for targeted work on a specific skill or assignment. Form will be automatically submitted to the ELC when you press the submit button. Print a copy for the student to bring to the ELC and one for your records.

Instructor's First Name:
Instructor's Last Name:
Instructor's Email Address:	*Note: This needs to be your @nhmccd.edu email address.

Student's ID:
Student's First Name:
Student's Last Name:
Student's Email Address:

Statement of Need:

Suggested Activities:

Recommended Mandatory

Date to be Completed By: