Student & Textbook Information Sheet 2016-2017        Teacher: Phillip Kirk

Class Period _______             Course:   Honors Chem  /   General Chem    /   Chem & Society                                                                                                                                                  (Circle One Course Above)

 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



    Inside:          Cover 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 this sheet to ensure that there will not be any unidentified damages and fees charged at the end of the year.