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What is your first name?
Your answer
What is your last name?
Your answer
What teacher did you have last year?
Your answer
What language do you mostly speak at home?
Your answer
What language do your parents read at home?
Spanish
Vietnamese
English
Other
Clear selection
What language do your parents most speak at home?
Spanish
Vietnamese
English
Other
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How many homes do you have?
1
2
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Who do you live with?
Your answer
Do you take the bus home?
Yes
No
Sometimes
Clear selection
Do you walk home?
Yes
No
Sometimes
Clear selection
Do you go to Boys and Girls Club?
Yes
No
Sometimes
Clear selection
Do you get picked up?
Yes
No
Maybe
Clear selection
Do you have any allergies? If yes, what?
Your answer
Do you have any medical conditions that I should be aware of? (asthma, glasses, etc.)
Your answer
Do you have a computer at home?
Yes
No
Maybe
Clear selection
Do you have internet at home?
Yes
No
Maybe
Clear selection
Do you have a printer at home?
Yes
No
Maybe
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Do you have a cell phone?
Yes
No
Maybe
Clear selection
Have I had any of your sisters or brothers in my class? If so, who?
Your answer
Do you enjoy reading?
Yes
No
Maybe
Clear selection
What types of books do you like to read?
Your answer
What is your favorite subject and why?
Your answer
Write your home phone number and parents cell phone number.
Your answer
Is there anything about you that I should know? Is there anything you want to tell me about you?
Your answer
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