Form for identifying study-related problems

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* Indicates required question

Email *

Your email

Your relationship to the student. S/he is my *

Your answer

Name of the student: *

Your answer

Date of Birth: *

MM

/

DD

/

YYYY

Gender: *

Male

Female

Prefer not to say

Class & course in which he/she is studying: *

Your answer

The most important problem *

Your answer

The second most important problem *

Your answer

The third most important problem *

Your answer

Comments, if any

Your answer

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