VINE ACADEMY

TEACHER REFERENCE FORM

Your Name *

Date *

Your Contact Number

Your Email *

Applicant's Name *

School / organization and subject you taught the applicant

In your experience, how does this student perform academically?

Does well academically

Does average work academically

Does below average work academically

Has significant difficulty in academics

Please explain how the stundent performs and behaves in your classroom

On the basis of factual academic information (report cards, transcripts, etc.), what is the applicant’s ability in the following areas? Please place a checkmark in the category that best describes the student’s ability

MATH

Above Average

Average

Below Average

Has Significant Difficulty

READING COMPREHENSION

Above Average

Average

Below Average

Has Significant Difficulty

WRITING

Above Average

Average

Below Average

Has Significant Difficulty

Please describe any special academic programs, either remedial or enriched, in which this applicant has been enrolled

Please select one of the following to describe the applicant’s character and general behavior.

This individual has been an exemplary student

This individual has performed reasonably well

This individual has needed disciplining from time to time

This individual has been discipline problem

Comment

Does the applicant cooperate with faculty and staff in his/her behavior and attitude?

All the time

Most of the time

About half of the time

Some of the time

Generally uncooperative

In your opinion, what are the leadership qualities of the applicant? The applicant is:

Accepted by his/her peers as a leader and naturally takes control of situation

A natural leader, but accepts leadership roles reluctantly

Not a leader, but integrates well with other students

Not a leader and has difficulty integrating with other students

Comment

In your opinion, what is the applicant’s most outstanding characteristic?

Is there an area of his/her life that needs special attention? Please explain:

To the best of your recollection, please describe the school activities in which this applicant has participated. (Sports, choir, drama, clubs, etc.)

From your experience, has there been parental cooperation and involvement in school activities?

Yes

Comment

Are you aware of any emotional issues in this student that should be brought to our attention?

Yes

If yes, please explain

Please add further confidential comments that would assist us in evaluating the applicant.

May we contact you by phone for additional information?

Yes

Comment

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