Students Last Name______________________________

Information Sheet

Student's Name ( First, Last, Preferred) _____________________________________________

Contact Name (First, Last, Relationship) ____________________________________________

Contact Phone Number__________________________________________________________

Contact e-mail address(parent)____________________________________________________

Contact e-mail address(student)___________________________________________________


  1. Do you have Internet access at home? 
    • ___  Yes  ____No

  2. Are you color blind?
    • ___  Yes  ____No

  3.  Do you have an after school job?
    • ____Yes  ____No  
    • How many hours per week?______
Record ofHome Contact
Do not write in this box)
Procedures and Rules Acknowledgment

I, ___________________________________ (student's name) have read and agree to follow all of the safety rules set forth in the laboratory safety policy and the course syllabus. I realize that I must obey these rules to insure my own safety, and that of my fellow students and instructors. I will cooperate to the fullest extent with my instructor and fellow students to maintain a safe lab and classroom environment. I will also closely follow the oral and written instructions provided by the instructor. I am aware that any violation of the safety policy and/or the syllabus that results in unsafe conduct in the laboratory or misbehavior on my part, may result in being removed from the laboratory, disciplinary referral, receiving a failing grade and/or dismissal from the course.

Student Signature Date

We feel that you should be informed regarding the school's effort to create and maintain a safe science classroom/laboratory environment. With the cooperation of the instructors, parents and students, a safety instruction program can eliminate, prevent and correct possible hazards. You should be aware of the safety instructions your son/daughter will receive before engaging in any laboratory work. Please read the course syllabus and the laboratory safety policy. No student will be permitted to perform laboratory activities unless these policies are signed by both the student and parent/guardian and are on file with the teacher.
Your signature on this contract indicated that you have read the laboratory safety policy and the course syllabus; are aware of the measures taken to insure the safety of your son/daughter in the science laboratory; and will instruct your son/daughter to uphold his/her agreement to follow these rules and procedures in the class and the laboratory.
Parent/Guardian Name (print) Signature Date

Please return the signature sheet to Dr. Croom in Room 104