Personal Information

First Name:___________________________ Last Name:___________________________

Where born?

How long in the United States?

How long in Coos Bay/North Bend?

Where are some of the places lived?

Where are some of the places visited?

Where are some of the places you want to visit?


Goal: Why studying English?

_____ to read / write English _____ College English

_____to talk English _____ English with children

_____to computer / Internet _____ English for work

_____Citizenship / Naturalization _____ GED

_____to meet people / friends _____ to eat


Married Single Widowed Divorced

Spouse:___________________________ Spouse’s work/school:______________________

Children: Age & Grade

School(s): Teacher(s):

Other family members here:

Other family members there:



What job name


Church Sports Crafts Arts

Personal Characteristics

What color hair? What color eyes? How tall?

What kind of: clothes, shoes, jewelry usually

What animal are you?

Favorite Things

What is your favorite…?

Color__________ Ice Cream __________ Vegetable______________ Fruit_______________

Type of

Movie:____________________ Example is like :____________________________________

Celebrity:__________________ Example is like :____________________________________

Music:____________________ Example is like :____________________________________

Breakfast:_________________ Example is like :____________________________________

Lunch:____________________ Example is like :____________________________________

Dinner:____________________ Example is like :____________________________________

Restaurant:_________________ Example is like :____________________________________

Car:____________________ Example is like :____________________________________

TV Show:___________________ Example is like :____________________________________

American customs you like:

American customs that confuse you:

American customs you want to change:

What do you want to study this term?