Student Data Sheet
First Name: ______Last Name:______
Nickname: ______
(If you prefer to be called something different than your original name)
Current Age: ______Date of Birth:______
Month/day/year
Home Address: ______
City:______State: Texas Zip code:______
Home Telephone Number:______
Student E-mail Address:
Parent/Guardian #1 Name: ______
E-mail:
Cell Number:______
Place of Employment:______
Occupation:______
Work Phone:______
Parent/Guardian #2 Name:______
E-mail:
Cell Number:______
Place of Employment:______
Occupation:______
Work Phone:______
How many siblings do you have that live in your home?______
How many siblings do you have in total?______
Do you work outside of school during the school week? (Circle) yes or no
If yes, where?______
If no, do you plan on finding a job during this semester?______
How many hours a week?______
**Parent/Guardian****************************************
Please verify that the above information is accurate and sign in the space below:
______
Parent/Guardian Signature
Circle all that apply.
Vision problems: nearsighted (can’t see far) and/or farsighted (can’t see near)
ADD
ADHD
Hearing impaired
Diabetic
Asthmatic
ESL/ESOL
Dyslexic
Other info the teacher should know: ______
What are your hobbies?______
Are you currently involved or plan to be involved in any of the activities below this year?
If yes, circle all that apply.
Football Drama Literary Magazine Drill Team
Baseball Orchestra Fashion Club Dance Team
Basketball Band Debate Other: ______
Softball Choir Freshman Core Other:______
Swimming ROTC Sophomore Core
Tennis Ag/FFA Junior Core
Wrestling Student Council Senior Core
Track Key Club Cheerleading
Cross Country Foreign Language Club Pep Squad
Soccer Yearbook
Golf
What do you plan on doing after graduating from high school?
(Circle all that apply)
Attend a Community college Military Other:______
Attend a University Undecided
Technical school Find employment
Do you know what profession/occupation you would like to pursue? If yes, explain: ______
What is you least favorite subject?______
What is your favorite subject?______
How many hours per school night do you intend to devote to homework?______
What time of day do you complete most of your homework?______
Where do you complete most of your homework? Circle answers below:
HOME: in my bedroom, in living room, in kitchen Other: ______
SCHOOL: in class, in resource room, library, study hall Other:______
When you are doing your homework, are there other things going on?
Siblings around, other students talking, tv, music, Other: ______
As a student, what skill(s) do you feel you most need to improve on?
Listening
Writing
Reading
Studying (i.e. memorizing, recalling, practicing, learning how to study for tests/quizzes)
Organizational (i.e. keeping papers organized/remembering important due dates)
Participating (i.e. learning how to be how to be comfortable in sharing my opinion in groups and amongst class)
Behavior
Writing Sample
1. Choose one writing prompt
2. Write in Complete sentences.
3. Use correct punctuation.
4. Write in Paragraph form.
What three things can I as the teacher do to help you become more successful as a student in this class?
What three things can you do as a student to help yourself be more successful this year?
When have you felt particularly successful in school?
______
______You may add additional notebook paper if you need more space. Staple to this packet.