Name of student:
 
DOB
 
Sex(M/F)
 
Grade
 
Parent legal guardian)
 
Address:
 
City: ST:
 
Zip:
 
Email:
 
Classroom Teacher:
 
Teacher Email:
 
Favorite subject(s):
 
  How do you learn best? (check all that apply)
 
I learn best when I work independently.
 
I learn best when someone is sitting near me.
 
I learn best when I am working at a desk.
 
I learn best when I can touch things.
 
I learn best when I can read a book.
 
I learn best when I can create artwork to go along with my learning.
 
I learn best when I can talk about things with another person.
 
I learn best when I listen to music while I am working.
 
I learn best when in a bright room.
 
I learn best when the lights are low.
 
I learn best when I can go at a faster pace.
 
I learn best when I can go at a slower pace.
 
I learn best when I can choose the order in which I do things.
 
I learn best when I work in the mornings.
 
I learn best when I work in the evenings.
 
I learn best when I have a break every hour(s).
 
I learn best when I have time to work on projects I enjoy doing.
 
I learn best when I am given lots of opportunity to practice.
 
I learn best when I can perform in front of a crowd.
 
I learn best when I can keep a journal of what I have learned.
 
 
Which subjects are your most challenging and why?
 
 
If you could study 3 specific topics this year, which topics would you study and what 3 questions would you want answered?
 
Question 1
 
a
 
b
 
c
 
Question 2
 
a
 
b
 
c
 
Question 3
 
a
 
b
 
c
 
 
Check the activities that you would like to create this year.
 
Advertisement
 
Audio Take
 
Book
 
Brochure
 
Bulletin Board
 
Speech
 
Cartoon
 
Learning Center
 
Chart
 
Collage
 
Concept Map
 
Dance
 
Debate
 
Demonstration
 
Diagram
 
Diorama
 
Editorial
 
Essay
 
Flow Chart
 
Game
 
Interview
 
Journal
 
Magazine Article
 
Map
 
Mobile
 
Model
 
Mural
 
Newspaper
 
Newscast
 
Oral Report
 
Painting
 
Pantomime
 
Persuasive Speech
 
Picture Dictionary
 
Poem
 
Pop Up Book
 
Poster
 
Puppet SHow
 
Rap
 
Riddle
 
Scavenger Hunt
 
Scrapbook
 
Simulation
 
Song
 
Story
 
Survey with Graph
 
Talent Show
 
Timeline
 
Travelogue
 
Trivia Game
 
Wordless Book
 
Written Report
 
If you could learn about 3 careers, which careers would you want to learn more about?
 
1
 
2
 
3
 
At this year's science fair, what will your exhibit be about?
 
 
  Share 3 goals you would like to set for yourself this school year.
 
1
 
2
 
3
 
How can your teacher support you in reaching these goals?
 
 
  What would you like to talk about to your teacher this year?
 
 
 
What types of clubs would you be interested in joining?
 
Book club
 
Math club
 
Science club
 
Church group
 
Future problem solving
 
Chess club
 
Scouting
 
Sporting club
 
Would you be interested in moderating an internet chat on a subject area you know a lot about?
 
Yes
 
  Would you be interested in joining a book discussion chat?
 
Yes
 
What else would you like your teacher to know about you?