Secondary Student Reference Form

Reference for Students Applying to Grades 9-12
Today's Date *

Month Day Year
Student Applying for Admission *

First Name Last Name
How long have you known the student? *
Does the student attend church regularly? *

Yes No Unsure
Does the student regulary participate in church activities? *

Yes No Unsure
Does the student come from a Christian home? *

Yes No Unsure
Does the student come from a well disciplined home? *

Yes No Unsure
Is the student inclined to receive instruction? *

Yes No Unsure
Does the student yield to discipline? *

Yes No Unsure
Does the student interact well with others? *

Yes No Unsure
Does the student have any significant limitations in the physical, mental, emotional, or social realms? *

Yes No Unsure
If so, please explain.
What are some strengths you have recognized in this student? *
Has the student, to your knowledge, ever been disciplined, suspended, or expelled from school? *

Yes No
If so, please explain.
Have you observed anything that would question this child's ability to succeed in a Christian school? *

Yes No
If so, please explain.
Have you ever known the student to drink alcoholic beverages, use tobacco products, or illegal drugs? *

Yes No
If so, please explain.
Would you want your own child associating with this student? *

Yes No
Why or Why not? *
Please add any additional commnets.
The fields below relate to the person completing this form.
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Relationship to Applicant *
Signature (Use your mouse to sign.) *
Should be Empty:

Reference for Students Applying to Grades 9-12