Chemistry Student Information 2008-09

First Name (Use the name you would like to be called in class.)

Last Name

Student ID #

Gender

Female
Male

Who is your chemistry teacher?

Floyd Routt Tankersley White

Race/Ethnicity

Caucasian/White African-American/Black Hispanic Asian Pacific Islander Native American Multi-Racial Other

Which option best describes your English language abilities?

Native born English speaker ESOL Level 1 ESOL Level 2 ESOL Level 3 ESOL Level 4 ESOL Level 5

Period you have chemistry:

G1 G2 G3 G4 I don't have you for chemistry, I'm just checking out the form R5 R6 R7 R8

Parent 1 Name

Parent 2 Name

Home Phone (7 digits only)

Your cell phone (optional)

Parent 1 Daytime Phone

Parent 2 Daytime Phone

Your Email Address:

Parent 1 Email Address

Parent 2 Email Address

Have you passed the English portion of the GQE?

Yes No Haven't take it yet

Have you passed the math portion of the GQE?

Yes No Haven't take it yet

Do you usually do well in science courses?

Yes Somtimes No

How do you like math?

I love math. I'm okay with math. I struggle in math classes. I dislike math. I hate math.

How well do you take tests?

I usually do well on tests It depends, but I mostly do well on tests I sometimes don't test well I really hate taking tests; I'm a bad test-taker

These are my favorite subjects (select all that apply):

English/Literature
Mathematics
History
Science
Social Sciences (psychology, sociology, etc)
Instrumental Music
Vocal Music
Physical Education
Art
Graphic Design
Computer Programming/Web Site Design
Computer Server Management
Medical Careers
Engineering/Design
Home Economics
Child Care
Auto Repair
Auto Body Repair
Accounting

What is your main career interest? ("Undecided" is an acceptable answer.)

After high school I will probably...

pursue a career directly related to chemistry. pursue a career related to other sciences. pursue a career unrelated to science.

Do you understand that you have to sign up and pay for ACP to get college credit for this course?

Yes

Are you allergic to any of the following?

Latex
Nuts
Bee Sting
None of these

Do you have one of these?

IPod/MP3 Player IPod/MP3 with video capabilites No, I don't own one of these.

Describe your Internet access away from school:

high speed access (cable/DSL) phone line access I go to the library for Internet access I do not have Internet access away from school

How much are you looking forward to taking chemistry?

This is my second time taking it. I think I'll love it. It will be okay. I'm not sure yet. I think I'm going to have problems. You'd better start talking to my counselor now...