Application for Admission Request for Reference – Community Representative

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Under the provisions of the Family Education Rights and Privacy Act of 1974, this applicant (if admitted and enrolled) will have access to the information provided below unless he/she waives such access.

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To be completed by Applicant:

1. Name of Applicant __________________________________________

2. Middle School ______________________________________________

3. (Optional) I hereby waive my right of access to the material recorded below.

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Signature of Applicant                                                                                                Date

 

To be completed by Respondent:

	Superior	Above Average	Average	Below Average	No Information
Intellectual Ability
Writing Ability
Speaking Ability
Problem-solving Ability
Responsibility
Leadership Ability
Behavior
Interpersonal Skills
Respect
Motivation
Perseverance

 

I have known the applicant for approximately ______________ years.

In the capacity of__________________________________________________________

 

In summary:

Highly recommend Recommend Recommend with reservations Do not recommend 

 

Respondent’s signature: ___________________________ Title ___________________ Date_________

 

Name Printed or typed:____________________________________________________

Address________________________________________________________________

 

To the Respondent: May we have your judgment of this candidate’s qualifications, and promise of the candidate’s intellectual ability, motivation, respect, responsibility and capacity for rigor.

(You may use the back side of this sheet.)

Please return this form to: Applicant in a sealed envelope.