Vital Statistics Form - Dr. W.A. Kritsonis

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 _____________________