Mr. L's Survey - Survey Form

Please complete the form as completely as possible. Most of these fields must be completed. Several are optional and may be left blank if you do not wish to answer them. Options fields are marked with a red asterisk* Important information is marked in red
Today's Date	(Example) 00-00-00
First Name
Middle Initial	(Do not include a period)
Last Name
Gender	Male Female
Age In Years	(Example) 13
Home Phone #	(Example) 000-000-0000
Mom's Cell Phone# *	(Example) 000-000-0000
Dad's Cell Phone #*	(Example) 000-000-0000
Mom's Last Name If Different *
Dad's Last Name If Different *
Mom's Email Address *
Dad's Email Address *
Homeroom
Locker #	(Example) 000 (Do Not Include The Letter C In Front Of The Numbers)
Check The Subjects That You Enjoy The Most In School.	Language Arts Social Studies Math Science Physical Education Art
English Book #	(Example) 0007LA (Include All Numbers and Letters)
Describe Any Damage That Is In This Book, And Include The Page # Where Found. If There Is No Damage In Your Book Enter The Word (none) In This Box.
Spelling Book #	(Example) 0007LA (Include All Numbers and Letters)
Describe Any Damage That Is In This Book, And Include The Page # Where Found. If There Is No Damage In Your Book Enter The Word (none) In This Box.