STUDENT INTAKE FORM 2011 - 2012 SCHOOL YEAR
Students please complete this form and hit submit.  Your answers will be used as a part of my National Board Certification process.  Your cooperation is most appreciated.  Thank you.  Your individual results will remain confidential and you will be given credit for the completed form once it has been submitted.
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Last Name *
First Name *
Parent's Last Name *
Ex:  Smith
Parent's First Name *
Ex:  Michelle
Parent/Emergency Contact Number *
Parent/Guardian email address:
Grade *
Required
Age *
Required
Sex: *
Required
Race/Ethnicity *
Required
In what state or country were you born? *
Primary language spoken at home: *
Required
Do you currently have a part-time job? *
Required
Do you participate in at least one school sponsored extra curricular activity? *
Clubs, Athletics, etc.
Required
Do you participate in at least one volunteer/community activity outside of school? *
Required
Twitter account name
(not mandatory, but only if you wish to share) ex:  @thebuzzwithberk
Email address: *
What does education mean to you? *
This can be a few, short words or a paragraph.
Intended College Major or Career Aspiration? *
If you already have an idea on what you would like to major in, please indicate that here.  If not, what careers are you interested in pursuing?
Thank you for taking the time to complete this survey.
Your answers to this survey will remain anonymous and are used for analytical and data reporting purposes only.  Please check your responses prior to hitting submit.  Once you hit submit, you will not be able to go back to edit your responses.  

Thank you and I am looking forward to an exciting year of biology!
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