SAMPLE
XYZ Charter
719
555/555-1234
Six Weeks Membership Survey (Sample)
Use Black or Blue Ink Only
(This form is an
EXAMPLE to show you how to fill out the Membership survey)
Course: English 101
Period: A1
A2 A3 A4
B1 B2 B3
B4
(Circle only one)
|
Grade |
Number
of Students in Membership |
Student
Detail |
Difference |
|
K |
|
|
|
|
1 |
|
|
|
|
2 |
|
|
|
|
3 |
|
|
|
|
4 |
|
|
|
|
5 |
|
|
|
|
6 |
|
|
|
|
7 |
12 |
|
|
|
8 |
6 |
|
|
|
9 |
|
|
|
|
10 |
|
|
|
|
11 |
|
|
|
|
12 |
|
|
|
|
Total |
18 |
|
|
Transfer the number of students by grade level from your
class rosters to this form as shown above.
Then sign, date, and put in the office in a tray marked Membership
Survey.
Teacher Signature
Date
Reconciled by:
Attendance Official
Date
III. 4