Student Survey 2015-2016
(Please clearly. This information is for your teacher’s use only and will not be shared
with anyone else.)
Course: _________________________________________
My Full Name is (first and last): _______________________
My parent(s)/guardian(s) name(s) and contact number(s)-work/cell are:
(Indicate using number who I should call in order)
Mom(s): ___________________________
#
______________________________
Dad(s): ____________________________
#
______________________________
Guardian(s): ________________________
#
______________________________
(This is so I can discuss with them your progress, successes and challenges at time too so they can help me to support you).
My home telephone number: is :__(
) _____________________________
My e-mail address is: ________________________________________________________
My birthday is: _______________________________________________
My last school was (if different than Vaughan Road Academy) _____________________________
My learning preferences are:
(Please rank your preference with 1 as your favourite and 3 as your least favourite)
1) I like working best: ______ by myself (independently)
_____ with a partner
___ in a small group
2) I will feel most comfortable to work and concentrate in class if I am sitting:
____ at the front of the class
____ in the middle of the classroom
____ at the back of the class
3) I understand instructions or how to do something best when (check as many as apply here)
____ it is written down on a sheet of paper
____ it is said to me aloud
____ it is accompanied by a diagram, picture or example ____ I try to figure it out myself
I have an IEP (individualized Education Plan) yes
no (circle one)
Please explain any special learning needs that I should know about (hearing or sight deficiencies,
processing (speech/language difficulties, gifted, attention deficit A.D.D. or other) so that I can best
ensure that your learning needs are met and accommodated.
What I am most looking forward to or hoping to learn in this class… (could be content-based or skillbased)
I really want to improved on or learn how to (as it relates to the course specifically)
Three things you should know about me as a learner are:
(Ex. I like to have an exemplar so I know exactly what the teacher is looking for)
1.
2.
3.
The extra-curricular activities I plan to be a part of this semester are (both in and outside of school)
An important question that I have for you as my teacher is/something I want to tell you as my
teacher…
The ideal classroom for me… looks like, sounds like, feels like… Explain 