Heritage Academy                                                                                                    Counselor or Administrator Evaluation

Applicant’s Name _________________________________Applying for Grade________

Counselor or Administrator Evaluation

Name of person completing this report: _______________________________________________________________

Name of school: _________________________________________________________________________________

1. I have known the above applicant for __________________ as his/her __________________________________

2. This report is based on: _____ Personal observation and contact with student _____ Teacher Comments ________

Other counselor’s observations _____ Records ____ Other (explain) _______________________________

3. The student has been sent to the office for disciplinary reasons: ____ Often ____ Seldom ____ Never

Please describe problem(s) ________________________________________________________________________

_______________________________________________________________________________________________

______________________________________________________________________________________________

4.This student has been suspended _____ times. Reason(s) _____________________________________________

5. Has the applicant been expelled or dismissed from school for academic or disciplinary reasons and therefore not

eligible to return? ____ Yes ____ No Explain: __________________________________________________

6. Do you have any reason to doubt this student’s academic integrity? ________ Yes _______ No

7. The applicant’s attendance has been: ______ Excellent _____ Good _____ Poor

8. The applicant’s parents can best be described as: (Circle as many as apply)

Involved Cooperative Difficult Uninvolved

Tends to blame school for student’s problems

9. Does the applicant have any significant limitations (physical, social/emotional, academic/learning disabilities)

Please describe: __________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________