Why Im Here Form

Media Purpose

Student Name: ____________________________

Date: _______________

Responsible teacher: _______________________

Arrival time: _________

Estimated time needed in media center: _______

Departure time: ______

Nature of Assignment: __________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
Request help from Media Specialist?
If yes, nature of help needed:

YES

or

NO

__________________________________________________

_____________________________________________________________________________
Should this student be using the computer? YES

or

Should this student be interacting with other students?

NO
YES

or

NO

Should this student be working with or without certain materials? YES or NO

If so, explain: _________________________________________________________________
Special Comments: _____________________________________________________________