Application Reference (Counselor)

Application for Admission Request for Reference – School Counselor

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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.

___________________________________________________ ________________________

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.

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