Students Name: First Name Last Name Thank you for your time in filling out this assessment form. We highly value your opinion, and this information is extremely important to us. All information will be held in the strictest confidence. Please note, we can only process this application once we have received this form. Reference Name: First Name Last Name City: Relationship to Student: ex. teacher, neighbor etc Cell Phone: Area Code Phone Number E-mail: Best time to reach you: How Long do you know the Student? How frequently do you interact with the student? 1. Commitment to Torah/Chassidishe Identity Please rate the student's traits from 1-4. (1= very much so, 2= mostly, 3= at times, 4= rarely) Is it apparent that she has Yirei Shomayim? 1 2 3 4 Is she careful to be Tzniyus at all times? 1 2 3 4 Does she set her Tzniyus Standards only because of school rules? 1 2 3 4 Does she conduct herself in a Chassidishe manner? 1 2 3 4 Learning Easily learns new concepts? 1 2 3 4 Is attentive in class? 1 2 3 4 Participates in class discussions 1 2 3 4 is respectful of authority, rules and policies: 1 2 3 4 Is open and eager to new learning experiences: 1 2 3 4 Is consistant with school attendance and punctuality: 1 2 3 4 Completes work and assignments responsibly: 1 2 3 4 Personality/Character Respects others: 1 2 3 4 Has a positive outlook: 1 2 3 4 Values honesty & Integrity: 1 2 3 4 Takes responsibility for her actions and words: 1 2 3 4 Adaptable & Flexible 1 2 3 4 Shares her feelings or opinions: 1 2 3 4 Extends herself outside her own inner circle: 1 2 3 4 Is sensitive to others: 1 2 3 4 Stands up for what is right: 1 2 3 4 Is self-confident: 1 2 3 4 Conducts herself with Menchlichkeit: 1 2 3 4 Contributes or volunteers: 1 2 3 4 Demonstrates interest in personal growth: 1 2 3 4 Has leadership qualities: 1 2 3 4 Takes responsibility for her personal appearance (hygiene etc.) 1 2 3 4 Please describe the student in a few sentences: Is there anything else you feel we should know to enable us to best help the student? By typing your name below, you are stating that the above information is true and that you agree that your electronic signature is the legal equivalent of your manual signature on this application. Signature* Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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