Student Interest Survey

Mrs. Palmer
Name: _____________________________

Class Period: _____________

Name you want me to call you: ____________________________ (if different)

Your birthday: _________________
Parent or guardian name(s): ______________________________________________
Preferred daytime phone number: __________________________________________
May I leave a message? ____________
Email address of parent/guardian: __________________________________________
***** YOUR email address: _______________________________________________
(I will never use it. Sometimes, students email me work and do not put their name on the email.
I do not open attachments if I do not know who the email is from).
Mailing address: ______________________________________________________
__________________________________________________________________
Name & age of siblings: _________________________________________________
About you:
Do you take part in any activity/sport/club at Riverdale HS? Which one(s)?

What sports and activities interest you outside of school?

Do you have responsibilities/chores on a regular basis at home? What?

Do you have a job? How many hours per week do you work?

Do you have access to internet outside of school?

What do you like MOST about school?

What do you like LEAST about school?
What is your favorite school subject?
What are your goals in the future? Do you plan to attend college?
What grade do you plan on making in this class?

What are your favorites?

Type of music/band/singer:

Movies:

TV shows:

Books:

Food & drinks:

What is important to you/about you?

Please list 3 important events in your life that define or describe you and the year they
happened:
1.
2.
3.
Is there anything unusual or unique in your life that you think I should know in order to make
this semester better for both of us?