First through Eighth Grade Educator Referral FormFirst through Eighth Grade Teacher Referral FormThis form is to be completed by the teacher or school.Applicant Name* CHILD’S FIRST NAME LAST NAME DATE OF BIRTH APPLYING TO GRADE Applicant Name* FORM COMPLETED BY: FIRST NAME LAST NAME Applicant Name* POSITION EMAIL PHONE NUMBER Applicant Name* SCHOOL NAME CHILD’S ENROLLMENT START DATE END DATE Applicant Name* WHAT IS THE CHILD’S PRIMARY LANGUAGE? HOW LONG HAVE YOU KNOWN THIS CHILD? I AM THE CHILD'S: CURRENT TEACHER PREVIOUS TEACHER OTHERWHAT WORDS COME TO MIND TO DESCRIBE THIS STUDENT?FOR EACH ITEM LISTED BELOW, PLEASE CHOOSE THE MOST APPROPRIATE DESCRIPTION:MAKES TRANSITIONS EASILYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABILITY TO WORK IN A GROUPCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABILITY TO WORK INDEPENDENTLYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPOSITIVE INTERACTION WITH PEERSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPOSITIVE INTERACTION WITH ADULTS/TEACHERSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVELISTENS AND FOLLOWS DIRECTIONSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABILITY TO FOCUS ON TASK AT HANDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEAPPROPRIATE USE OF CLASS TIMECONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEINTELLECTUAL CURIOSITYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEMOTIVATION/EFFORTCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEABILITY TO EXPRESS IDEAS IN WRITINGOUTSTANDINGABOVE AVERAGESATISFACTORYNOTICEABLY WEAKNEEDS IMPROVEMENTABILITY TO EXPRESS IDEAS ORALLYOUTSTANDINGABOVE AVERAGESATISFACTORYNOTICEABLY WEAKNEEDS IMPROVEMENTSEEKS HELP WHEN NEEDEDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEUSES LANGUAGE TO PROBLEM SOLVECONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVESHOWS CONSIDERATION FOR OTHERS, EMPATHYCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEDESCRIBE THIS STUDENT'S APPROACH TO LEARNING (HANDS ON, VISUAL, KINETIC, AUDITORY, LOGICAL):WHAT ARE THE STUDENT'S STRENGTHS?WHAT ARE THIS STUDENT'S CHALLENGES? DESCRIBE ANY AREAS MOST NEEDING SUPPORT OR ADULT SUPERVISION (ACADEMIC OR PERSONAL):DESCRIBE THE STUDENT'S ABILITY TO WORK INDEPENDENTLY AND IN GROUPS:DESCRIBE THE STUDENT'S ABILITY TO DEVELOP FRIENDSHIPS AND RESOLVE CONFLICTS:DESCRIBE THE STUDENT'S ABILITY TO INCORPORATE CRITICISM FOR GROWTH:DESCRIBE THE STUDENT'S MOST IMPORTANT ACCOMPLISHMENT IN YOUR CLASS:DESCRIBE THE FAMILY'S PARTNERSHIP IN THE SCHOOL COMMUNITY:FAMILY ENGAGEMENT: FOR EACH ITEM LISTED BELOW, PLEASE CHOOSE THE MOST APPROPRIATE DESCRIPTION:COOPERATES WITH CLASSROOM TEACHERSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVERESPECTFUL OF TEACHERS' TIMECONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVECOMMUNICATES WITH THE SCHOOLCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEFOLLOWS THROUGH WITH THE SCHOOL RECOMMENDATIONSCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEFOLLOWS RULES AND POLICIES OF THE SCHOOLCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEFAMILY HAS REALISTIC EXPECTATIONS OF THE CHILDCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEIS PUNCTUAL WITH DROP-OFF AND PICK-UP PROCEDURESCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEPARTICIPATES IN SCHOOL ACTIVITIESCONSISTENTLYOFTENSOMETIMESRARELYNO OPPORTUNITY TO OBSERVEIS THERE ANY INFORMATION PERTAINING TO THIS CHILD/FAMILY THAT WOULD BE BETTER COMMUNICATED BY PHONE? YES NOTHE BEST NUMBER AND DAYS/TIMES TO REACH ME ARE:Δ
