Union Springs Academy - Student Recommendation Form

Your Name

______________________________________

Your Position

______________________________________

Your Phone Number

______________________________________

The confidental recommendation below is for (student's name)

______________________________________

How well do you know the student? (choose one) Well / Some / Little / Records Only

For how many years? _____

Please circle the adjectives that most nearly describe the applicant's standing on the items listed below.

Christian Experience Dedicated Growing Searching Uncommitted	Intellectual Aptitude Quick to Learn Average Must Study Hard to Learn Educational Disability	Leadership Potential Natural Latent Follower
Christian Influence Positive Passive Negative	Academic Motivation Self-Starter Needs Supervision Persevering Easily Discouraged Apathetic	Personality Extroverted Well-balanced Reserved Self-Confident Tactful Outspoken
Choice of Friends Chooses Wisely Somewhat Wisely Somewhat Carelessly Chooses Carelessly	Industriousness Resourceful and Enthusiastic Reliable Erratic Often Late Easily Distracted Not Interested in Work	Personal Relationships Makes Friends Easily Self-Centered Unselfish Easily Offended Accepts Criticism Antagonist
Strength of Character Firm, Steady, Consistent Fairly Stable Weak, Easily Influenced	Cooperation Helpful Works Well With Others Non-Compliant	Emotional Stability Self-Controlled Stable Easily Disturbed Unstable
Trustworthiness Very Trustworthy Generally Trustworthy Tends to be Dishonest	Personal Appearance Well Groomed Relatively Neat Careless Slovenly	Attitude Toward Authority Cooperative Passive Acceptance Grumbling Acceptance Rebellious
Church Attendance Attends Regularly Rarely Attends Never Attends

Has the applicant, to your knowledge, ever:

Used tobacco in any form?	Yes / No
Used alcoholic beverages?	Yes / No
Used illegal drugs of any kind?	Yes / No
Had problems with profane language?	Yes / No
Had problems with dishonesty?	Yes / No
Been involved in theft?	Yes / No
Been arrested or charged with a crime, or been in trouble with juvenile authorities?	Yes / No

If "yes" to any of the above items, please explain:

Do the applicant's parents meet financial obligations regularly?	Yes / No
Would you be willing to have the applicant room with your child?	Yes / No
If you were responsible for accepting students at Union Springs Academy, would you vote to accept this student?	Yes / No

_______________________________
Signature

___________________
Date

Remarks:

Please Mail or Fax to:

Union Springs Academy
40 Spring Street P.O. Box 524
Union Springs, NY 13160

Fax: (315) 889-7188