Student & Textbook Information Sheet 2011-2012        Teacher: Phillip Kirk

Class Period _______ Course    AP Chem / Honors Chem / Chem & Society                                                                                                            (Circle One)

 Name ___________________________________ Student ID#____________ Birth Date _____________  (Last, First MI)

Home #______________________ Cell #_______________________ Work #_____________________

Address   __________________________________

                __________________________________

Parent(s) and/or Guardian(s) Name(s) and Phone Numbers

 ___________________________ Home ______________ Cell _____________ Work ______________

 ___________________________ Home ______________ Cell _____________ Work ______________

Do you wear contacts?______ If yes, do you have a pair of glasses that you can wear? ______

I would also like to remind you that contact lenses should not be worn in the chemistry laboratory. OSHA, the American National Standards Institute and the American Chemical Society all agree that contact lenses can hold foreign materials against the cornea, are difficult to remove in case of a splash and can absorb and retain chemical vapors. Even though students are required to wear chemical splash goggles when working with chemicals, it is a good policy to avoid contact lenses on lab days. There will be lab days on which contacts are prohibited.

Do you have any allergies?______ If yes, to what? (Foods, Chemicals, Medications)

If you are currently on medication, or during the course of the year begin taking a medication, then you should ask your doctor about possible interactions in a high school laboratory. If either you or your doctor has any questions then request a complete list of chemicals used in this course. All MSDS are available and everything used in class is labeled.

Book Number(s): ____________ General Book Condition(s): _____________

    Outside:       Front & Back Cover

                        Spine

                        Corners

 Inside:          Cover Pages

                        Pages

Students are asked to record the current condition of the text book they were assigned. Any damages to the text that are found and that were not recorded could be charged to you and your son / daughter at the end of the semester. Please look over the Information Sheet to ensure that there will not be any unidentified damages and there will not be a fee charged at the end of the year.