* Required

For School Administrators, Teachers, and Community Leaders

Applicant and School Administrator/Teacher/Community Leader Information

Applicant Namerequired

Administrator/Teacher/Community Leader First Name:required

Administrator/Teacher/Community Leader Last Name:required

School/Organization:required

Position/Title:required

Daytime phone:required

Administrator/Teacher/Community Leader Emailrequired

Student Background

How well do you know the student as a person?required

How well do you know the student academically?required

Has the student ever been dismissed, suspended, placed on probation, or received other serious disciplinary actions? *

Yes No

Student Evaluation

Please select the option for each item below that represents your evaluation of the student in comparison to other students in his or her age group whom you have taught or advised. If you have no fair basis for judgement, do not hesitate to say so.

Academic potentialrequired

Academic achievementrequired

Intellectual curiosityrequired

Effort/determinationrequired

Ability to work independentlyrequired

Organizationrequired

Creativityrequired

Willingness to take intellectual risksrequired

Concern for othersrequired

Honesty/integrityrequired

Maturity (relative to age)required

Responsibilityrequired

Respect accorded by teachersrequired

Respect accorded by peersrequired

Overall evaluation as a studentrequired

If the student is relatively weak or strong in any areas above, please elaborate.

What are the first three words that come to mind to describe this student? required

Please comment on the student's character, citizenship, and contributions to your community. required

Signature

Thank you for taking your valuable time to complete this evaluation. Your reflections are an important part of the candidate's application. All information you provide will be held in confidence and disclosed only to the Selection Committee and others deemed necessary by the administrators of the program.

Namerequired

Daterequired (mm/dd/yyyy)

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