Student Reference Form

STUDENT REFERENCE FORM
Student Applicant Name:*
Name of Student Applying to Fountainview Academy
The above named individual is applying to become a student at Fountainview Academy. 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.
How long have you known the applicant?*
In what capacity have you known him/her?*
Please rate the applicant on a scale of 1 (weaker) to 5 (stronger) for each of the following areas. Check-mark any descriptors that specifically describe the applicant for each area or add your own descriptors in the comments section.
1. Spirituality
Weaker

weakstagnatingantagonistic

Spirituality Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

strongstablegrowingopen
Spirituality Comments
2. Relation to Authority
Weaker

disrespectfulantagonisticoutward obediencesullen

Relation to Authority Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

respectfulcooperativeappropriately submissive
Relation to Authority Comments
3. Integrity
Weaker

dishonestnot trustworthymanipulative

Integrity Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

honesttrustworthyconscientious
Integrity Comments
4. Helpfulness
Weaker

unawareself-centeredapathetic

Helpfulness Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

helpfultakes initiative
Helpfulness Comments
5. Learning/ Academics
Weaker

unmotivatedcarelessslow learner

Learning/Academics Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

highly motivateddoes their bestlearns easily
Learning/Academics Comments
6. Judgment (Reasoning Ability)
Weaker

headstronglacks common senseimpulsive

Judgement (Reasoning Abilities)*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

level-headedcarefulsoundwiseteachable
Judgment Comments
7. Emotional Stability
Weaker

tenseexcitableoften loses controlmoodyfearful

Emotional Stability Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

well-balancedcontentself-controlledcheerful
Emotional Stability Comments
8. Personal Appearance
Weaker

draws undue attentionworldlycareless

Personal Appearance Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stonger

modestneatwell-groomedtasteful
Personal Appearance Comments
9. Conversation
Weaker

shallowinappropriate

Conversation Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

sensibleappropriatekinduplifting
Conversation Comments
10. Social Acceptance
Weaker

dislikedfew friendsclingy

Social Acceptance Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

well-likedmany friendsleader
Social Acceptance Comments
11. Relation to Opposite Gender
Weaker

flirtysecretiveoverly dependent

Relation to Opposite Gender Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

circumspectopenhealthybalanced
Relation to Opposite Gender Comments
12. Influence on Others
Weaker

detrimental

Influence on Others Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

positive
Influence on Others Comments
13. Industriousness
Weaker

lazyunmotivatedunwilling

Industriousness Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

hard workerefficiententhusiastic
Industriousness Comments
14. Health
Weaker

weaksicklylow vitality

Health Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

vigorous healthenergetic
Health Comments
15. Parents' Financial Responsibility
Weaker

irresponsiblenot a priority to pay bills

Parents' Financial Responsibility Rating*

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

very responsiblebills paid currently
Parents' Financial Responsibility Comments
Has the applicant had any trouble concerning conduct in school or elsewhere?*
If so, what was the nature of the problem?
Has the applicant:*

drank alcoholdone drugssmokednone to my knowledgeOther
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 recommendedrecommendedrecommended with reservationnot recommended under the present circumstancesnot recommended under any circumstances
Your Information
Name:*
Occupation:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Country CodeArea CodePhone Number
E-mail*
Should be Empty:

STUDENT REFERENCE FORM

1. Spirituality

2. Relation to Authority

3. Integrity

4. Helpfulness

5. Learning/ Academics

6. Judgment (Reasoning Ability)

7. Emotional Stability

8. Personal Appearance

9. Conversation

10. Social Acceptance

11. Relation to Opposite Gender

12. Influence on Others

13. Industriousness

14. Health

15. Parents' Financial Responsibility

Your Information