Application for Admission Request for Reference – School Counselor
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.
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:
I have known the applicant for approximately ______________ years.
In the capacity of__________________________________________________________________
Highly recommend Recommend Recommend with reservations Do not recommend
Respondent’s signature: ___________________________ Title ________________ Date_________
Name Printed or Typed:_____________________________________________________________
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.