Chemistry: Student Information and Classroom Management Plan Agreement / Student Safety Contract Student Name:___________________________________________________________________________ Last First Middle Initial Preferred Name: _____________________________________________

Home Phone #: ________________________________ Student Cell #: __________________________

Birthday: ___________________________________ (please include the year)

Parent/Guardian Name: ________________________________________ Relationship: _______________ Last First Work Phone #: __________________ Email: __________________________________________________

Parent/Guardian Name: ______________________________________ Relationship: _______________ Last First Work Phone #: ______________________ Email: ______________________________________________

Home Address: ________________________________________________________________________________________ Street City/State Zip Code

Do you have an after school job? ____________ If so, what? ____________________________________

Do you wear contact lens? __________ Are you color blind? _________ If you have a medical issue (allergies, diabetes, asthma, etc) that I should be aware of, or if you have any questions or concerns, please include them here: ________________________________________________________________________________________

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________________________________________________________________________________________ I,__________________________________ (student) and __________________________________ (parent/guardian) have read the Course Syllabus and Student Safety Contract (adapted from Flinn Scientific’s Student Safety Contract). I understand what is expected of students in the Chemistry classroom, and I understand the need for safe behavior during lab exercises. Any misbehavior on my part that results in unsafe conditions and/or interferes with the learning environment may result in removal from the classroom setting and/or the consequences stated in the classroom management plan. I agree to the rules and will abide by them. We are also aware of the various opportunities provided by the teacher(s) to ensure academic success. Student’s signature ________________________________________________________________________ Parent/Guardian’s signature _________________________________________________________________ Date: ______________________________