Math 110 Student Information Form
First Name   Last Name  
Phone  

Cell Phone 		Email Address  
How do you prefer to be contacted?
email address
phone number cell phone
When did you last take a math class?
less than one year ago
1 to 2 years ago
2 to 5 years ago
over 5 years ago
 Where did you last take this math class?
at South Seattle Community College
at another community college
at a four-year college/university
in high school
as home study
other

What was this last math class?
   

What grade did you earn in that
last math class?
   

What is your primary program of study?

Is there anything you would like to share with me about your mathematics background?
Discuss anything you feel might affect your success in this math class.
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