Student Information Sheet

Student Name __________________________ Subject ____________

first)
Age __________ Birth Date __________ English English Place of Birth _________________ Spanish Spanish ___________ (other) ___________ (other)

(Last,

Primary language you speak (circle one) Primary Language spoken in your home

Do you play a musical instrument --- YES Which subject do you do best in ---

NO ? Instrument __________________ MATH NO NO ? ENGLISH ? HISTORY ?

SCIENCE

Have you read a book in the past 3 months --- YES Have you ever worn glasses or contacts --YES

Book ____________

What do you do for fun? _______________________________________________

Do you have any older brothers or sisters living at home --- YES

NO

Do you have any younger brothers or sisters living at home --- YES NO ? Have you ever had to repeat any of the following courses:
MATH SCIENCE HISTORY ENGLISH OTHER

Results from Learning Styles Assessment: AUDITORY

VISUAL

TACTILE