Sample Student Information Form
This is a *sample* form that would be completed by students at the start of a class in which social media tools will be used for learning activities.

Instructions: Please complete the information below to help me understand more about you and your individual learning needs. Required questions are marked with an asterisk (*).

First Name
Your answer
Last Name
Your answer
I have read and agree to the "Conditions of Participation" section of the the course syllabus.
If you select "No," I will contact you directly to discuss your concerns.
I have read and agree to abide to our "Community Groundrules."
If you select "No," I will contact you directly to discuss your concerns.
Check all that describe you.
Required
I have access to a digital camera or phone that I can use to take digital pictures.
I have access to a computer with a microphone or webcam that I can use for this class.
Do you have an iPhone, iPad, or iPod Touch?
If so, you can use the free VoiceThread app!
Which type of learning environment is more appealing to you?
Student-centered learning encourages students to create, collaborate, and contribute. Teacher-centered learning requires students to memorize and recite information.
Student-Centered
Teacher-Centered
You will be required to leave voice or webcam comments in this class. Which of the following methods will you use to do so?
How do you feel about the idea of sharing your ideas through voice comments in our class VoiceThreads?
In one word, describe how you are feeling about this class.
Your answer
What is one characteristic of a great online class?
Your answer
If you have a certified learning or physical disability that requires an accommodation, please let me know here. This is a private exchange.
Your answer
Is there anything you'd like to share with me at this point?
Your answer
Submit
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