DEMOGRAPHIC SURVEY

Please fill in the information below. You may want to print this page first, if you do not have all of the information immediately available. If some information is unknown or not applicable, please leave it blank. We will contact you if I need additional information or clarification.

Thank you for participating in this research! Remember, this information is confidential and will only be used by the research team and you are free to withdraw from this study at any time. Please feel free to email questions to me at franklabanca@sbcglobal.net

Name:*
Address:
City/State/Zip:
Phone number:
Alternate phone number:
email:*
Age:
Grade:
School Name:
School Address:
School City/State/Zip:
School phone number:
Principal:
Guidance counselor:
Current High School courses:	Please provide a list of courses that your are currently enrolled. Be sure to indicate the level (e.g. AP, Honors, College Prep, etc).
Teacher who helped with your project most:
Teacher's phone number:
Teacher's email:
What subject does this educator teach?:
Area of expertise:
How did this teacher help you?:	Please write a short sentence.
Parent(s)/Guardian(s) name(s):
Parent/Guardian phone number:
Parent/Guardian email:
Did your parent(s)/guardian(s) help with your project?:	Yes No
How?:	Please write a short sentence.
Mentor's name:
Mentor's affiliation:	Where does this person work?
Area of expertise:
Mentor phone number:
Mentor email:
How did your mentor help you?:	Please write 1 or 2 sentences.
Notes:	Is there any additional information or clarification to the above information that you would like to provide?