Secondary Student Reference Form

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

MonthDayYear
Student Applying for Admission*

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

YesNoUnsure
Does the student regulary participate in church activities?*

YesNoUnsure
Does the student come from a Christian home?*

YesNoUnsure
Does the student come from a well disciplined home?*

YesNoUnsure
Is the student inclined to receive instruction?*

YesNoUnsure
Does the student yield to discipline?*

YesNoUnsure
Does the student interact well with others?*

YesNoUnsure
Does the student have any significant limitations in the physical, mental, emotional, or social realms?*

YesNoUnsure
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?*

YesNo
If so, please explain.
Have you observed anything that would question this child's ability to succeed in a Christian school?*

YesNo
If so, please explain.
Have you ever known the student to drink alcoholic beverages, use tobacco products, or illegal drugs?*

YesNo
If so, please explain.
Would you want your own child associating with this student?*

YesNo
Why or Why not?*
Please add any additional commnets.
The fields below relate to the person completing this form.
Name*

First NameLast Name
Phone Number*

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

Reference for Students Applying to Grades 9-12