Student Information Sheet 2017-2018

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1. What is your last name? *

2. What is your first name? *

3. What is your street address? *

4. What city do you live in? *

5. What is your zip code? *

6. What is the best email address to contact you? *

7. What period do you have this course? *

8. What grade are you currently in? *

9th

10th

11th

12th

9. What course are you currently taking? *

Academic Chemistry

Honors Chemistry

AP Chemistry

Physical Science

10. What is your parent/guardian 1 name? Please include first and last name. *

11. What is the best number to contact parent/guardian 1? *

12. What is the best email address to contact parent/guardian 1? *

13. What is your parent/guardian 2 name? Please include first and last name.

14. What is the best number to contact parent/guardian 2?

15. What is the best email address to contact parent/guardian 2?

16. What out of school activities and/or responsibilities do you have? *

17. Which of the following best describes your electronic access at home? (Mobile devices or tablets do not constitute as a computer) *

I have adequate access to a computer and the internet

I have adequate access to a computer but not the internet

I have adequate access to the internet but not a computer

I have access to the internet but only through a tablet or other mobile device

I do not have access to a computer or the internet

18. Why are you taking this course? *

19. How will this course be beneficial to you in the future? *

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