HONORS CHEMISTRY
STUDENT INFORMATION SHEET
Student Name and Nickname (Print)______
Home Phone Number______
Student E-Mail Address (if you have one)______
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Mother's Name______
Mother's Occupation______
Mother's Work Number______
Mother's E-Mail Address (if she has one) ______
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Father's Name______
Father's Occupation______
Father's Work Phone Number______
Father's E-Mail Address (if he has one)______
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Last Math Course Completed______Grade Earned _____/_____
Science Course(s) Taken Last Year______Grade Earned _____/_____
Do need any special accommodations? Please explain.______
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Do you have an IEP or 504 plan? YES NO
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Do you have Asthma and / or Allergies? YES NO
If yes, please list specifics ______
Circle level of reaction: Mild Moderate Severe
Do you Wear Contact Lenses? YES NO If yes, what Type? ______
List Any Other Health Concerns: ______
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Do you have a computer and internet access at home? YES NO
Do you have a smart phone? YES NO
Please list any extracurricular activities that you are planning to be involved in this school year. (Ex. Football, School Play, Working at McDonalds …) ______
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Do you plan on attending college after high school? If yes, where would you like to attend and what would you declare as your major? ______
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Teacher Call Log
Date Reason for call Date Reason for call
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