What is your name?
____________________________________
What do you like to be called? _________________ Period: ____
What kind of technology access Check the box next to whichever statement describes you best.
do you have at home? Check
I already have a job and will keep working during the school year!
everything that you have!
I only work during the summer when I have more free time.
Desktop Computer
I hope to get a job sometime this year!
Laptop
I wish I had a job, but my parents don’t want me to get one yet.
iPad or Tablet
I am WAY too busy with school and/or sports to have a job.
Smart Phone
Other: ________________________________________________
Internet Access
None of the Above
What was the most fun
I could teach someone all about…
thing you did this summer?
If I had to guess how many
books are in my house, I would
because I am basically an expert!
say there are about
! Four positive words that I would use to describe myself are...
This number includes children’s
books, chapter books, books
that belong to my parents and
siblings, recipe books, etc.
My favorite teacher EVER was Starting with kindergarten,
When I was 5, I wanted to be a(n)… _________________________, how many different schools
have you attended
_____________________________. and I liked his or her class
(including this one)?
because __________________
Now, I want to be a(n)…
__________________________ How many siblings,
_____________________________. nieces, nephews, or little
__________________________!
cousins live with you?
What’s something FREE that you enjoy doing? ___________________________
What’s something FUN that you enjoy doing? ______________________________
What’s something that you COLLECT? __________________________________
How many pets
What’s something that you want to LEARN TO DO? _________________________ do you have at
your house?
© English 10 Mother Hen, 2017
What sports or clubs might you do this year? What kind of a LEARNER are you?
Check all that apply!
_______________________________________________ Visual/Spatial
_______________________________________________ Auditory/Musical
Kinesthetic/Physical
_______________________________________________
Verbal/Linguistic
Logical/Mathematical
I felt proud when... Social/Group Work
Solitary/Independent
I Really Don’t Know Yet!
Someday, I would like to ___________________________________________________________________.
My FAVORITE THINGS to
How long is your daily trip to MY BIGGEST GOAL FOR
LEARN ABOUT AS A KID
THIS YEAR:
were… school and how to get here?
___________________________
What responsibilities do you have at home? When is your
Ex: taking out trash, babysitting duty, etc.
*Name at least 3-4 topics of interest! birthday?
1. _____________________________ MONTH:
How do you try to STAY ORGANIZED?
________________________________ 2. _____________________________ DAY:
________________________________
3. _____________________________
Now, put a dot on the line below YEAR:
indicating your level of organization.
4. _____________________________
NEARLY LIVING SUPER Thank you for
IN CHAOS. ORGANIZED! 5. _____________________________ doing this
survey!
© English 10 Mother Hen, 2017
