Age_________ Birthday__________ Home Phone number__________
Address ________________________________________________
Directions the following questions are designed to help me to get to know you and to make helping you with your school work as positive an experience as possible. Questions that you do not feel comfortable about or are not sure of the answer you may leave blank, but please try to answer as many as possible. If you need more room you may draw an arrow to the back of the page and continue there or continue writing on a separate sheet of paper. If you use another sheet please make sure you put your name on the top.
Mother's Name ________________________ work number_______________
Mother's place of employment_______________________________________
Father's Name ____________________ work number_____________________
Father's place of employment_______________________________________
What other schools have you attended? _________________________________
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Are you supposed to wear glasses? _____________ If yes, when did you first get
them? ____________________________________________________________
Do your eyes bother you when you read or write? ______________ In what
way? __________________________________________________________
Is your hearing (circle one) excellent, good, fair, or poor?
Is your health (circle one) excellent, good, fair, or poor?
How many hours do you sleep each day? _______________________________
What I like most about myself. _________________________________________
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Is there anything you dislike? _________________________________________
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What do you intend to be? ___________________________________________
Why? _____________________________________________________________
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Are you planing on going to college? ___________________________________
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Do you have a pet? (Circle one) YES NO What is it? ______________________
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Write about your favorite music. ______________________________________
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Write about your favorite TV show or movie. ____________________________
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Do you like school? (Circle one) YES NO Why or why not? __________________
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Do you read for pleasure? _______________ If yes, name some of the recent books or magazines you have read. ____________________________________
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Is your reading (circle one) excellent, good, fair, or poor?
Do your parents encourage you to read at home? _________________________
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Estimate (guess) how many books are in your home. _______________________ _________________________________________________________________
Which library or libraries can you get to easily? Check all that apply
Church Library__________ School Library_________________
Public Library_____________ Any other(s) (write in) _________________________________________________________________
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From what sources other than libraries and your home, do you obtain books/ stuff you read? Check below.
Buy them_____________ Gifts_______________ from Friends___________________
Do you read the newspaper? Circle your answer YES NO
If yes what sections do you like best? Number them 1-6 in the order you like them, with #1 as your favorite.
Sports________ Funnies__________ Stories___________ News____________ Editorials_______________ Others___________________________________ _________________________________________________________________
Would you like to write for a newspaper this year? Circle your answer YES NO
Why? ____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What kind(s) of reading do you like? Check the ones you like. If you have a favorite put a star next to that one. Put a (w) next to any you have written. If you would like to write that kind this year put a (L) in the (w) box. If there is a kind you have never read or do not know about circle it/them.
3 k w
| Historical fiction | Plays | Travel | |||||||||
| Science fiction | Fairy Tales | Music | |||||||||
| Adventure stories | Biographies | Essays | |||||||||
| Detective stories | Autobiographies | ||||||||||
| Novels | History | ||||||||||
| Poetry | Science | ||||||||||
Other(s)___________________________________________________________
Do you currently or have you ever kept a journal? _________________________
If so do you enjoy journal writing? _____________________________________
What is the most interesting topic you like to study? _______________________
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What is the least interesting topic you must study? ________________________
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Have you been to a (check the ones you have visited):
_________ Farm ___________ Circus ___________ Zoo
__________ Museum _________Concert ____________Ballgame __________Play ___________College
If a college, which one? __________________________________________________
Write about some of the places that you have visited outside of (Charleston)______________________________________________________
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What interests do you have outside of school? ___________________________
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What school activities do you enjoy? ___________________________________
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Circle the word that shows how most teachers think of you as a student: excellent, good, fair, or poor. What kind of student do you think you are? __________________________
Is your spelling: excellent, good, fair, or poor?
Is your vocabulary: excellent, good, fair, or poor?
Is your grammar: excellent, good, fair, or poor?
In this English/ Language Arts class what do you specifically hope to learn about or improve? ______________________________________________________
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What else do you think I need to know about you to make this year a happy and successful one for you? ______________________________________________
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Please draw something you enjoy in the box bellow.
*** no drugs or sexual images please!