This document is a vital statistics form for a student containing their personal contact information, emergency contact, education history, work experience, hobbies, and career goals. The student provides their name, address, email, phone numbers, place of employment, degrees earned, years of teaching and administrative experience, favorite travel locations, number of children, hobbies outside of work, highest desired career position, and signs agreeing to course expectations.

1. Vital Statistics Form (Confidential)
Name_________________________ Student ID________________ Date__________
Complete Address _______________________________________Zip______________
Email: ____________________________ Alternative Email ____________________
Home Phone _______________________________ Cell _______________________
Work Phone _______________________________ Pager ______________________
In case of emergency, contact: Name ________________________________________
Home Phone: __________________ Cell _________________ Other ______________
1. Place of employment ______________________________________________
2. Current Position __________________________________________________
3. Name of School(s) ________________________________________________
4. Highest degree earned-PhD, EdD, EdS, MEd., MS, MBA, BA., BS., AA.
List institutions and degrees earned below: Institution-Degree-Year
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. What degree are you currently working? ___________
6. List a few of your favorite states and foreign countries you have visited:_______
_________________________________________________________________
_________________________________________________________________
7. Years of teaching experience: _____ Years of administrative experience: _____
8. Voluntary (optional) Number of children/grandchildren, names, ages:
_________________________________________________________________
_________________________________________________________________
9. What do you enjoy doing when you are not working?
_________________________________________________________________
10. What is the highest position you want to obtain in your career?
_________________________________________________________________
11. Is there something about you that Dr. Kritsonis needs to be made aware of?
(Please write on the back of this paper)
I, __________________________ am currently enrolled in the course entitled:
______________________________________. Dr. William Kritsonis is the
professor. I have read the course expectations. I understand what is
required and expected of me to satisfactorily complete the course.
Signed: _________________________________ Date _____________________