Back to School Survey
Ms. Bliss
Room 204
Grade 3
School 9
Welcome to Back to School Night. Please fill out this form so I have your contact information. If anything changes please let me know.
Optional fields are marked with a
red asterisk*.
Examples and important information are indicated in
blue.
Parent/Student Information
Student's First Name
Last Name
Mom/Guardian
Dad/Guardian
Street Address
Street Only
Home Phone Number
Example 123-456-7890
Cell Phone
*
Email Address
*
Example john@aol.com
Best time to call
Mornings
Afternoons
Evenings
Weekends
Anytime
Student's Birthday
Example mm/dd/yyyy
How old is your child?
Choose age
7
8
9
10
How long have you lived in Clifton?
0-3
4-7
7 or more
Do you have any other children in this school?
Yes
No
What grade or grades?
None
Kindergarten
First
Second
Third
Fourth
Fifth
(To select more than one, hold down the "CTRL key)
Student's Favorite Subject
Math
Language Arts
Science
Social Studies
Tell me what your child likes to do for fun.
Read
Draw
Dance/Cheer/Gymnastics
Collect cards
Play Video Games
Play a Sport
Other Please Specify
If marked "OTHER" please specify
To select more than one, hold down the "CRTL" key
How does your child prefer to study?
With music
Silence
Watching TV.
With friends
Would you like to be a class parent?
Yes
No
Can you help out in the library?
Yes
No
What days? Please check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
What are some goals you have for your child this year.
Site Designed and Maintained by
J. Bliss
Last Updated 12/20/2006 07:28 PM