Student Information Form

Student Information

Please fill out all of the following data and click the "Submit" button when you are finished. Fields marked with a blue asterisk (*) are required.

Data About You

First name: *      Last name: *

What name/nickname should I use when I call on you in class?

Code name for posted grades: *
Grades are posted in the classroom. The "code name" is the name your grades will be listed under so you can find them. (Don't stress about what to pick--I'll be happy to change it for you if you need me to.)

Which class is this?:*
C1 Chemistry I (C block)
C1 Chemistry I (F block)
C1 Chemistry I (H block)
AP Chemistry II (A block)
Chemistry II C1 (A block)

Homeroom:      Class of:* 2009 2010 2011 2012      Student ID:      Textbook number:

Date of birth: January February March April May June July August September October November December , 1989 1990 1991 1992 1993 1994 1995

Contact Information

Home phone: *      Cell phone:

Address: , Waltham, MA 02452 02453

Email address:

IM screen name:      IM Protoctol: AIM    Yahoo    MSN    other:
(Optional. I ask for screen names so when you IM me with questions about homework, I'll know who the message is from.)

Previous Math/Science Classes

Please list your most recent math and science classes and your final grades in both. (This will give me an idea of where your strengths are and where you might need help.)

Time Commitments

Please list anything besides academics that will be making demands on your time (sports, jobs, activities, family obligations, etc.). Please mention which days of the week are affected, if relevant.

Fall: Winter: Spring:

Accomplishments

Please tell me anything you're particularly proud of and would like me to know.

Concerns

Please tell me what you're most worried/concerned about when you take chemistry.

Accommodations

Are there any accommodations (such as extra time, help with organizing, etc.) that you feel you need in order to be successful? Please list everything that you think you need, regardless of whether or not you have an IEP or section 504 plan.

Anything else a teacher should know?

Please describe anything else you think I should know in order to help you be successful.

Please print this page before you click the "Submit" button and bring a copy of the printout to class.

If you leave any fields that have a blue asterisk (*) blank, you will get an error message when you try to submit the page. If this happens, use your Back button and fill in the field with the error.