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

weak stagnating antagonistic

Spirituality Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

strong stable growing open
Spirituality Comments
2. Relation to Authority
Weaker

disrespectful antagonistic outward obedience sullen

Relation to Authority Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

respectful cooperative appropriately submissive
Relation to Authority Comments
3. Integrity
Weaker

dishonest not trustworthy manipulative

Integrity Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

honest trustworthy conscientious
Integrity Comments
4. Helpfulness
Weaker

unaware self-centered apathetic

Helpfulness Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

helpful takes initiative
Helpfulness Comments
5. Learning/ Academics
Weaker

unmotivated careless slow learner

Learning/Academics Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

highly motivated does their best learns easily
Learning/Academics Comments
6. Judgment (Reasoning Ability)
Weaker

headstrong lacks common sense impulsive

Judgement (Reasoning Abilities) *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

level-headed careful sound wise teachable
Judgment Comments
7. Emotional Stability
Weaker

tense excitable often loses control moody fearful

Emotional Stability Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

well-balanced content self-controlled cheerful
Emotional Stability Comments
8. Personal Appearance
Weaker

draws undue attention worldly careless

Personal Appearance Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stonger

modest neat well-groomed tasteful
Personal Appearance Comments
9. Conversation
Weaker

shallow inappropriate

Conversation Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

sensible appropriate kind uplifting
Conversation Comments
10. Social Acceptance
Weaker

disliked few friends clingy

Social Acceptance Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

well-liked many friends leader
Social Acceptance Comments
11. Relation to Opposite Gender
Weaker

flirty secretive overly dependent

Relation to Opposite Gender Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

circumspect open healthy balanced
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

lazy unmotivated unwilling

Industriousness Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

hard worker efficient enthusiastic
Industriousness Comments
14. Health
Weaker

weak sickly low vitality

Health Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

vigorous health energetic
Health Comments
15. Parents' Financial Responsibility
Weaker

irresponsible not a priority to pay bills

Parents' Financial Responsibility Rating *

	1	2	3	4	5

1 is Lowest, 5 is Highest

Stronger

very responsible bills 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 alcohol done drugs smoked 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
Your Information
Name: *
Occupation: *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Country Code Area Code Phone 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