Student Information Form

As your instructor, it is helpful for me to have certain information about you, mostly contact information so that I can reach you or your parent/guardian(s) outside of school hours. The answers you submit here are for my personal use only--if you are concerned about submitting personal information in a form on the Internet--and you should be!--verify that this is a secure form by looking for the padlock icon in your browser. I appreciate the time and effort you put into filling it out, and am happy to offer you a nominal amount of extra credit as thanks for completing this "assignment."

This form should take no more than 10 minutes or so to fill out. When you've finished, be sure to hit the "Submit" button at the bottom.

Personal Info

1. Who is your Conceptual Physics teacher?

2. Your first name

3. Your last name

4. Any other name or nickname by which you prefer to be called

5. Your e-mail address

6. A password that you'll use to access your grades

7. Your chat Screen Name (AIM preferred)
This is my:
     AIM screen name
     MSN screen name
     Google Chat screen name
     ICQ screen name
     I don't have a chat Screen Name

8. Your phone number

9. Your mailing address (including number, street, city, zipcode)

10. I have read the Academic Integrity section and agree to abide by it.

Parent/Guardian Info

11. Parent/Guardian #1's first name

12. Parent/Guardian #1's last name

13. This person is your:
     Mother
     Father
     Stepmother
     Stepfather
     Other (please specify how related):

14. Parent/Guardian #1's e-mail address

15. Parent/Guardian #1's mailing address

16. Parent/Guardian #1's home phone number

17. Parent/Guardian #1's work phone number

More Parent/Guardian Info

18. Parent/Guardian #2's first name

19. Parent/Guardian #2's last name

20. This person is your:
     Mother
     Father
     Stepmother
     Stepfather
     Other (please specify how related):

21. Parent/Guardian #2's e-mail address

22. Parent/Guardian #2's mailing address

23. Parent/Guardian #2's home phone number

24. Parent/Guardian #2's work phone number

More Stuff About You!

25. List any extracurricular activities that you're involved in at school

26. List the things you like to do on your own time

27. List three of your favorite musical artists

28. If you wish, enter any additional information here that you want to share with me that will help us to work together better in class.