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Student Survey
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* Indicates required question
Tell Me About Yourself...
What is your last name?
*
Your answer
What is your first name?
*
Your answer
What class period do you have Mrs. King?
*
Period 1
Period 2
Period 4
Is there a different first name that you would rather be called?
If YES, write the name below; If NO, leave blank.
Your answer
What is your current age?
*
Your answer
What is your birth date?
*
Please write as MM/DD/YY [Example: 03/08/99]
Your answer
Who do you live with?
*
Check ALL that apply.
Mother
Father
Stepmother
Stepfather
Older Brother(s)
Older Sister(s)
Younger Brother(s)
Younger Sister(s)
Grandmother
Grandfather
Aunt
Uncle
Other:
Required
What is your personal email address?
*
Please do NOT write your parents email address. If you don't have an email address, please write NONE.
Your answer
What language(s) do you speak at home?
*
Please check ALL that apply.
English
Spanish
French
Other:
Required
What language(s) do your parents speak?
*
Please check ALL that apply.
English
Spanish
French
Other:
Required
Do you have a computer at home?
*
Yes
No
Do you have internet access at home?
*
Yes
No
What is your favorite thing to do when you get home from school each day?
*
Your answer
Do you have any obligations/responsibilities besides school?
*
Check ALL that apply.
Work
Family responsibilities (ie: babysit a sibling)
After school Activities (ie: sports or clubs)
None
Other:
Required
Roughly, how many hour do you spend PER DAY on other obligations/responsibilities besides school?
*
If you answered NONE above, put 0 below.
Your answer
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