Teacher Referral Form

The student below is applying to SUMMERBRIDGE — a tuition-free academic enrichment program held at Collegiate for high-need students who are struggling but have potential. 80% of our students must be eligible for free and reduced meal plans in JCPS. The program seeks motivated, talented students toparticipate in its six-week summer session.

Summerbridge is committed to a diverse student body representing the variety of ethnic and economicbackgrounds in the Louisville area.

SUMMERBRIDGE LOUISVILLE

902 S. SHELBY ST.11

LOUISVILLE, KY 40203

Thank you for your help in this process!

Student's Name

First NameLast Name

School Attended

Student Gender

MaleFemaleNon BinaryDo No Wish to Specifiy

Teacher Name

First NameLast Name

Referring Person's E-mail*

Teacher Phone Number

Area CodePhone Number

Please check below:*

	Excellent	Fair	Good	Poor
Student exhibits academic motivation
Student has a good attitude towards homework
Student exhibits good writing skills
Student exhibits good math skills
Student exhibits intellectual curiosity
Student is willing to try new activities
Student demonstrates leadership
Student works well alone
Student has self-confidence
Student reacts well to criticism
Student has concern for their fellow students

Do you know of any special interests, talents, or abilities this student has which would be helpful for us to know?*

How could Summerbridge particularly benefit this student? What might this student bring to Summerbridge?*

I recommend this student

Teacher Referral Form

Student Assessment