Confidential Report Form

Student Name

First Name

Last Name

Other Name

1) To your knowledge, has this student ever been required to repeat a year/grade level?

YesNo

2) Has the student ever been recommended for additional learning support?

YesNo

3) Are there any concerns about the student's learning or behavioural issues?

YesNo

If yes, please elaborate:

4) Has the student been involved in any serious disciplinary issues?

YesNo

If yes, please elaborate:

5) ESL Support required?

YesNo

Emergency Contact

6. What are this student's greatest strengths?

And areas of concern:

7. Please indicate the appropriate level for this student (1 = Low, 5 = High):

Inquirer - shows natural curiosity, a researcher, learner

1 (Low)2345 (High)

Communicator - receives and expresses ideas confidently

1 (Low)2345 (High)

Knowledgeable - has acquired a critical mass of knowledge

1 (Low)2345 (High)

Principled - sound grasp of morals, integrity

1 (Low)2345 (High)

Caring - sensitivity towards needs and feelings of others

1 (Low)2345 (High)

Leadership - shows natural leadership skills

1 (Low)2345 (High)

8. Please indicate the academic potential of this student (1 = Very Low, 7 = Very High):
1 (Very Low)234567 (Very High)

Would you recommend this student?
YesWith some reservationsNo

Please state your reservations (if any):

Please include any other relevant information:

Name of School:

Address of School:

Name:

Email:

Position:

Contact Number:

Date of Approval: