Reference Form
Name of Student
First Name
Last Name
Name of Reference
First Name
Last Name
Phone Number of Reference - for any follow up questions
Please enter a valid phone number.
Email of Reference - for any follow up questions
example@example.com
Relationship to student (teacher, coach, etc.)
What are this child's overall strenghts?
What makes this child unique?
What are some areas of concern, or how does this child deal with challenges?
Social-Emotional Development compared to typical peers.
Below Average
Average
Above Average
Exceptional
Cooperation
Leadership
Responsibility
Kindness
Inclusiveness of others
Work Habits compared to typical peers.
Below Average
Average
Above Average
Exceptional
Motivation
Listening Skills
Verbal Skills
Following Direction
Curiosity
Organixation
Self-regulation
How do the parents of this child support his or her strengths/weaknesses?
Do you have any other comments or concerns about this child's application to The Pelican School?.
Reference Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: