WITS STUDENT REGISTRATION FORM

Name:

School:

Teacher:

Name of Parent or Guardian:

Parent, Guardian, or Teachers E-mail:

Home Address:

City:

State:

Zipcode:

Home Phone Number and/or Phone Number to be reached on day of event:

Some background information

Date of Birth:

How often do you speak English at home?:

What is the highest level of education completed by your mother (or stepmother or female guardian)?:

What is the highest level of education completed by your father (or stepfather or male guardian)?:

What’s the highest level of education that you expect to complete?:

Why do you want to attend the WITS Institute?:

What do you like about science?:

	like it a lot	like it a little	not sure	dislike it a little	dislike it a lot
Designing and carrying out my own experiment
Coming up with a hypothesis/idea about a problem in science.
Watching the teacher do an experiment.
Finding out why an experiment worked.
Talking about how science is used in the “real world.”
Watching TV shows about science.
Reading books/magazines about science.
Listening to the teacher lecture about science.
Finding out what happens in an experiment.
Working with laboratory equipment in my science class.
Going to science museums.
Working by myself on science problems.
Visiting internet sites about science.
Working with others on science problems.
Working with technology in my science class.
Telling my family about what I did in science class.
The teacher telling me what to do in an experiment.

Food allergies or special dietary needs: