Name: __________________________________________ Date: ________________
Back to School Survey
1. If there is another name that you would prefer to be called other than the name that you wrote on the line at
the top of the paper, please write it here: ______________________________.
2. When is your birthday? _____________________________________.
3. Do you have internet access and a device that allows you to access the internet at home?
YES
NO
4. Do you have any siblings? Please list names and ages below if applicable.
5. Do you have any pets? Please list below if applicable.
6. There are so many wonderful subjects to learn here at school! What is your favorite and why?
7. Highlight the following statement that you believe fits you best:
 I learn best by listening/hearing
 I learn best by seeing/reading
 I learn best by creating/doing
 I learn best by teaching
8. Below, describe yourself in 2-3 complete sentences. Please tell me things about you that I would never know
just from looking at you. Please don’t describe your appearance – I can see that .
9. For this question, please tell me anything that you would definitely feel uncomfortable saying about yourself in
front of the whole class, but would definitely need me to know. This will remain 100% confidential. If you don’t
have anything, you can leave this one blank.
10. What can I do for you this year to help you have a good year? (The answer “don’t give a lot of homework” is
funny, but I am looking for something a bit more personal).
11. What is something that you feel strongly about, or have a staunch opinion on? Tell me why.
12. Tell me some characteristics of what you believe is a good friend?
13. Tell me some characteristics of what you believe is a good teacher?
14. Do you participate in sports, band, clubs, and/or any other extracurricular activities? If so, what?
15. Look around the room. Without speaking to anyone, tell me if there are one or a few people who you consider
to be your friend(s). List their names below.
16. What would you most like to see change from last school year? What would you hope stays the same?
17. Being as positive as possible…what are you looking most forward to this year? What are you not too thrilled
about/may be dreading?