Student Survey

Name: _______________________________________

Birth Date: ____________________________________ Life Coach: ____________________________________

Home Address: ___________________________________________________________________________________

Home Phone #:________________________________ Cell Phone #: __________________________________

Previous High School: ________________________________

E-mail Address: _________________________________________________________________________

Wh

at

I’d

lik

e t

o d

o/b

e w

hen

I

gra

duate

:

Qualities that characterize me: My favorite subject(s):

An

acc

om

plis

hm

ent

I am

pro

ud

of

& w

hy:

Qu

alit

ies

that

a g

ood

math

teach

er

has:

I think school is…

My least favorite subject(s):

How I feel about math:

The grade I expect in this class & why:

The Excel Center • Geometry • Term 3 • Ms. Miriam

Favori

te c

olo

r(s)

:My race / ethnicity / culture(s):

Child

/Ch

ildre

n (

Nam

e &

Ag

es)

:

My hobbies / strengths:

Places I have lived in:

Pla

ce o

f E

mp

loym

en

t &

Nu

mb

er

of

Hou

rs P

er

Week:

Lan

gu

ag

es

I sp

eak:

Favori

te T

V s

how

(s):

Favorite movie(s):

Why did you decide to come/stay at the Excel Center?

Favori

te s

nack

/food

/dri

nk:

Favorite book(s):

Challe

ng

es

that

mig

ht

make

it

diffi

cult

to s

ucc

eed

th

is

class

:

Who inspires you and why?

Wh

ere

I s

pen

d m

y f

ree t

ime:

How

do y

ou

get

to

sch

ool (Y

ou

dri

ve,

fam

ily m

em

ber

dri

ves,

b

us,

etc

.)?

ON

E T

HIN

G:

Best ways for me to learn something new (reading it, writing it, practicing/doing it, acting it out, hearing it, talking about it, etc.):

The Excel Center • Geometry • Term 3 • Ms. Miriam