Name:

Birthday:

Age:
I. B
Sex:
a
Parents:
c
Home Address: k
Date: g
round Information

A. Describe your family

B. Describe your school

C. What are your interests? Your hobbies? What do you do in your free time?
II. Learning Style

This will help determine your learning style.

On a scale of 1 - 3 (with 1 being the least often, and 3 being the most often),
rank your response to each situation. Please circle your answer.

Sample

Whenever I see a dog

I pet the dog. 3 2 1
I leave the dog alone. 3 2 1
I shoo the dog away. 3 2 1

When I am spelling a word

I try to see the word. 3 2 1
I sound out the word or use a phonetic approach. 3 2 1
I write down the word to find out if it feels right. 3 2 1
When I am talking to someone
I speak sparingly, and dislike listening for too long. I favor
3 2 1
using words such as see, picture, and imagine.
I enjoy listening, but Im impatient to talk. I favor using
3 2 1
words such as hear, tune, and think.
I move around a lot, using gestures and expressive
3 2 1
movement. I use words such as feel, touch, and hold.
When I am trying to concentrate
I am distracted by untidiness and movement. 3 2 1
I am distracted by sounds and noises. 3 2 1
I am distracted by activity, and things happening around
3 2 1
me.

When I meet someone again

I tend to forget their names, but remember their faces or
3 2 1
where we met.
I tend to forget faces, but remember what we talked
3 2 1
about.
I tend to remember what we did together. 3 2 1
 When I contact people on business
I prefer direct, face-to-face, or personal meetings. 3 2 1
I prefer to talk over the telephone. 3 2 1
I prefer to talk to them while we walk around or participate
3 2 1
in an activity.
When I read
I like the descriptive scenes. I like pausing to imagine the
3 2 1
actions.
I enjoy the dialogue and conversation. I like hearing the
3 2 1
characters talk.
I prefer action stories. But in general, I do not read as a
3 2 1
leisure activity..
When I am doing something new
I like seeing demonstrations, diagrams, slides, and
3 2 1
posters.
I prefer verbal instructions, or talking about it with
3 2 1
someone else.
I would rather jump right in and try it for myself. 3 2 1
When I am putting something together
I first look at the directions and the picture. 3 2 1
I listen to instructions from someone. 3 2 1
I ignore the directions and figure it out as I go along. 3 2 1
When I need help with a computer application
I look for pictures and diagrams. 3 2 1
I call the help desk, ask a friend/neighbor, or growl at the
3 2 1
computer.
I keep trying to do it, or try to do it on another computer. 3 2 1

III. Further Questions

A. What do you want to learn? What activities would you like to do?

B. What are your expectations for the class?

IV. Diagnostic Activities

Use the bond papers provided.

1. On the first bond paper, select an item around the house and copy it as
closely as you can. Pleas use a pen or pencil only. Spend at least 10 minutes
on it.

2. On the second bond paper, draw a person or character using any style you
want. Please use various coloring materials (if available). Spend at least 10
minutes on it.

3. On the third bond paper, draw a place using any style you want. Please use
your various coloring materials ONLY (do not use a pencil or ballpen). Spend
at least 10 minutes on it.

4. On the fourth bond paper, draw whatever you wish. Spend at least 20
minutes on it. Please DO NOT COPY another picture or drawing.