Please indicate:	I do	I do not	waive any right of access I may have to this reference form.

Student signature:________________________________________________________ Date:___________________

Student Name: __________________________________________________________

Term for which tutorial is Proposed: _____________

STATEMENT OF PROSPECTIVE TUTOR

Tutorial is an integral part of a Special Concentration. Students undertaking interdisciplinary studies need attentive and challenging tutors; they frequently have difficulty finding them.

1) Are you willing to serve as this student's tutor for the academic term indicated above?

2) Would you explain how the syllabus or your tutorial contributes to the student's Special Concentration as described in the proposal and Plan of Study he/she has submitted to you?

Please feel free to attach additional pages to this sheet.

Signature:_______________________________________________________________Date:_________________

Name: (Please print)____________________________________________________________________________

Dept. & Dept. Title:____________________________________________________________________________

(The Committee on Special Concentrations appreciates the care and candor with which you will reply.)

Return to Lisa Laskin, University Hall North, Room 127, OR email to specialconc@fas.harvard.edu.