Student Reference Form

Student's Name:

Appraisal

Your honest and candid appraisal will assist us in making an informed decision regarding this student's compatibility with our spiritual, academic, and physical program. This referral will be kept strictly confidential.

For how long have you known the applicant?

In what capacity have you known him/her?

Please indicate the overall Rating in each category that best identifies the applicant's standing. Check any descriptors from the "Weaker" and "Stronger" columns which apply or add your own descriptors in the comments section. Rating scale: 1 = lowest, 5 = highest.

Characteristic « Weaker Rating Stronger » Comments
Spirituality
immature
stagnating
antagonistic
1 2 3 4 5
strong
stable
growing
willing
open
Relation to Authority
antagonistic
sullen
outward obedience
1 2 3 4 5
cooperative
intelligently submissive
Integrity
needs constant supervision
underhanded
1 2 3 4 5
very trustworthy
dependable
conscientious
Service Attitudes
indifferent
withdrawing
self-centered
1 2 3 4 5
unselfishly helpful
takes initiative
compassionate
Intellect
sluggish
dull
listless
slow
slow learner
1 2 3 4 5
very apt
superior
creative
learns easily
Scholastic Application
unmotivated
satisfied with defective work
listless
slow
slow learner
1 2 3 4 5
highly motivated
aims for perfection
Judgement (reasoning ability)
rash
foolish
lacks common sense
headstrong
1 2 3 4 5
careful
sound
wise
teachable
Emotional Stability
tense
excitable
often loses control
moody
fearful
1 2 3 4 5
self-controlled
well-balanced
serene
happy
Personal Appearance
slovenly
worldly
faddish
careless
1 2 3 4 5
crisp
modest
neat
well-groomed
Manners
coarse
rough
affected
false
uneducated
1 2 3 4 5
refined
courteous
properly
educated
Conversation
vulgar
coarse
sentimental
shallow
bad
1 2 3 4 5
pure
kind
true
sensible
uplifting
holy
Social Acceptance
disliked
few friends
clingy
1 2 3 4 5
well-liked
many friends
leader
Friendships
no standards
no discrimination
1 2 3 4 5
wise
discriminating
circumspect
chooses friends with high standards
Industriousness
lazy
gets by
unmotivated
unwilling
1 2 3 4 5
enthusiastic
good products
willing worker
Relation to Opposite Sex
very flirty
secretive
sentimental
attached
1 2 3 4 5
circumspect
open
healthy
very orderly
Health
weak
often incapacitated
low vitality
1 2 3 4 5
vigorous health
energetic
Influence on Others
detrimental
passive
1 2 3 4 5
strong for good
helpful
Parent's Financial Responsibility
poor risk
not a priority to pay bills
1 2 3 4 5
very responsible
bills paid currently

Has the applicant had any trouble concerning conduct in school or elsewhere?

If so, what was the nature of the problem?

The applicant has used: drugs alcohol tobacco none to my knowledge.

If you had a child at this school, would you be willing for the applicant to room with him or her?

Do you believe the applicant really wants to attend Fountainview?

What has been the home environment (stability, discipline, etc.) of the student?

Please give any further information that would be helpful in evaluating this applicant or in guiding him/her as a student.

To become a member of the student body of Fountainview, the applicant is:

highly recommended
recommended
recommended with reservation
not recommended under the present circumstances
not recommended under any circumstances

Name:
Occupation:
Address:
Phone:
Email Address:

Should we need to verify your submission, we ask that you supply a password that will uniquely identify you to our interviewers: