Student Information Sheet
Students/Parents/Guardians - please take a moment to complete this form and submit the information to Dr. Strubinger.  Thanks!



Items denoted with a red asterisk * are required.
 
 
Student Information Section 1:
 * Student Name:
 
First Name
M.
Last Name

(First, MI, Last)
Name you wish to be called?
 
 * Student e-mail address:
 

If you share an e-mail address with your parent/guardian, you may enter it above.
 
 
Parent/Guardian Information:
Please complete this for individual(s) with whom you live
 * Parent/Guardian Name #1:
 
First Name
M.
Last Name

(First, MI, Last)
 * Daytime Phone #1:
 
 -  - 
(home, work, or cell ok) Please be sure to list the telephone number at which it is easiest to reach you.

(XXX)-XXX-XXXX
Parent/Guardian #1 e-mail address:
 
Employer/Occupation:
 
 
 
Optional Parent/Guardian Information:
Parent/Guardian Name #2:
 
First Name
M.
Last Name

(First, MI, Last)
Daytime Phone #2:
 
 -  - 
(home, work or cell ok) Please be sure to list the number at which it is easiest to reach you.

(XXX)-XXX-XXXX
Parent/Guardian #2 e-mail:
 
Employer/Occupation:
 
 
 
Student Information Section 2:
 * Student's Current Chemistry Class
 
 * Student's Current Math Class:
 
Student's College/Career Aspirations?
 

Students, please let me know what you think you'd like to do in the future in the box above.
 * Student Hobbies/Interests/Extracurricular Activities
 

Please tell me about yourself in the box above!
 * Favorite Subject(s) & Preferred Learning Style
 

In the box above list your favorite subject(s) in school and complete this statement, "I learn best when instruction is..."
Additional info you would like to communicate to Dr. Strubinger:
 

Please be sure to include information about any special needs or health concerns in the box above.