Student Information Survey

Student Information Survey

Child’s Name: ______Date of Birth:______

Mother’s Name: ______Father’s Name:______

Step-Mother’s Name: ______Step-Father’s Name: ______

Home Phone#: ______Home E-Mail: ______

Mom’s Cell Phone#: ______Father’s Cell Phone #: ______

Mom’s Work E-Mail: ______Dad’s Work E-Mail: ______

Home Address: ______

Family Information

Please list siblings and ages: ______

Who does the student live with? (Circle all that apply)

Mother Father Stepmother Stepfather GrandmotherGrandfather Aunt Uncle

Other Household Members: ______

Do you have any pets at home? If yes, what type. ______

Would you like to share any information regarding religious background and/or holidays celebrated/not celebrated? ______

______

Medical Information

Is your child supposed to be wearing glasses? _____ For reading or board work? (Circle)

If your child is suppose to be wearing glasses, will he/she have them at school? ______

If not, please explain: ______

Describe any medical/physical conditions and food/medicine allergies your child has that I need to be aware of: ______

______

Additional Information

What can I do, as a teacher, to help your child be successful this year? Please write a few sentences to tell me more about your child. Include any of the following, or anything else you feel would help me get to know your child better: feelings about reading, math, or other subjects; study habits; your child’s social skills and how they relate to other children; situations at home that may influence learning (loss of pet, divorce, death of a family member, new baby at home, etc); concerns or worries that you may have concerning your child’s education. ______

______

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I am available to help with (check as many as possible)

_____Typing newsletters

_____Typing student work

_____Making teacher stuff on home computer (banners, etc)

_____Coming into the classroom to help students

_____Coming into the classroom to do teacher stuff (making copies, doing bulletin boards)

_____Doing teacher stuff at home (such as cutting or making class books)

_____Making extra copies at home

_____Helping with parties

_____Providing treats when asked

_____Field trips

_____Being a classroom parent

_____Other ______(tell me what you are good at!)

_____Just ask!

When are you available to help in the classroom?

Monday_____ Morning_____ Afternoon

Tuesday_____ Morning_____ Afternoon

Wednesday_____ Morning_____ Afternoon

Thursday_____ Morning_____ Afternoon

Friday_____ Morning_____ Afternoon

_____ I work an irregular schedule, but feel free to call and ask!

Career Day

Would you be willing to speak to a class on Career Day (date to be announced at a later date)

_____Yes

_____No

What is your profession? ______