Student Name__________________
Class ____________
_____ Excellent
_____ Good
_____ Fair
_____ Needs Improvement
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
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(This may include family outings,
camping, extra-curricular activities, etc.)
How much
time is spent per week? ______________________
Parent/Guardian Signature________________________ Date__________________