Release and Consent Form
Release and Consent Form Parents, please give a copy of this consent form and the attached Teacher Report to your child’s current classroom teacher. Applications will not be considered complete until we have received this form. Your signature on this form indicates that your child’s current classroom teacher has your permission to release his/her confidential evaluation of your child to St. Dominic School. Current Teacher, please complete and return the attached Teacher Report to: St. Dominic School 935 East 5th Street Benicia, CA 94510
We respectfully ask that you complete and return this form as quickly as possible in order to best facilitate the application process. The information on this form is confidential between you and the Administration of St. Dominic School. Student’s Name______________________________________________ (please print) Parent/Guardian Signature____________________________________________________ Date _______________________________________________________
(Revised 1/13)
St. Dominic Catholic School Confidential Teacher Report
Student Name ______________________________ Current Grade_____ Class Level: Academic Evaluation: Academic potential Academic achievement Self-motivation Effort, drive Study habits Ability to work alone Ability to work in a group Participation in discussion
Reads for pleasure Ability to express ideas orally Use of time Organization of work Follows directions Uses suggestions or corrections Critical and abstract thinking Seeks help when needed
Accelerated Fair Average Low Please check appropriate ratings for the following: limited
fair
average
considerably below expectations as expected better than tests
good
outstanding
somewhat below par far above expectations
does very little only that required sets high goals limited poor
occasional fair
needs much supervision needs help occasionally
usually good
good
rarely contributes contributes when called upon joins in readily if prodded
sometimes unable to cope always works well wants to dominate contributes occasionally
occasionally
limited has some difficulty average uses poorly usually uses well poor
fair
average
needs much explanation quickly and correctly rarely heeds
weak
occasional insight
frequently
exceptionally good
occasionally wastes always uses effectively good
excellent
occasionally needs help
needs reminding
rarely occasionally
excellent
needs help frequently always works well
has great difficulty usually effective
rarely
maximum
usually
frequently good
usually
always
always
exceptional
(Revised 1/13)
Attention span
easily distracted usually good
Maturity in terms of age & grade
very immature above average
cannot be trusted usually trustworthy
Integrity and honesty Consideration of others Social adjustment with peers
normal
questionable highly developed
thoughtless usually considerate
seldom considerate always considerate
has serious problems has frequent minor problems has occasional minor problems very healthy
troublemaker usually good
Classroom conduct
insecure
Emotional stability
withdrawn pleasing
Personality
occasionally disrupts always good
overly tense
attention getter
overly aggressive unusually interesting
rarely laughs or smiles
Sense of humor
normal
good
usually
always
stable
delightful
needs much reassurance appears overly confident needs some support healthy self-image
Self confidence Cooperates with adults Cooperation of parents passive sociable stubborn irritable
somewhat mature very mature
a follower leads when put in position seeks opportunities and uses them well a natural leader
Leadership potential
occasionally distracted exceptionally good
rarely poor
sometimes fair
good
outstanding
Please check words which best describe this student
vivacious good-humored friendly well-liked belligerent forthright aggressive sullen persistent cheerful self-centered poised easily discouraged influential (wholesomely, unwholesomely)
aloof shy nervous
Other Comments :
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Teacher’s Signature_______________________________________________
Date________________________
Subject Taught_________________________________ School_________________________________________
We respectfully ask that you complete and return this form as quickly as possible in order to best facilitate the application process. The information on this form is confidential between you and the Administration of St. Dominic School. Student’s Name______________________________________________ (please print) Parent/Guardian Signature____________________________________________________ Date _______________________________________________________
(Revised 1/13)
St. Dominic Catholic School Confidential Teacher Report
Student Name ______________________________ Current Grade_____ Class Level: Academic Evaluation: Academic potential Academic achievement Self-motivation Effort, drive Study habits Ability to work alone Ability to work in a group Participation in discussion
Reads for pleasure Ability to express ideas orally Use of time Organization of work Follows directions Uses suggestions or corrections Critical and abstract thinking Seeks help when needed
Accelerated Fair Average Low Please check appropriate ratings for the following: limited
fair
average
considerably below expectations as expected better than tests
good
outstanding
somewhat below par far above expectations
does very little only that required sets high goals limited poor
occasional fair
needs much supervision needs help occasionally
usually good
good
rarely contributes contributes when called upon joins in readily if prodded
sometimes unable to cope always works well wants to dominate contributes occasionally
occasionally
limited has some difficulty average uses poorly usually uses well poor
fair
average
needs much explanation quickly and correctly rarely heeds
weak
occasional insight
frequently
exceptionally good
occasionally wastes always uses effectively good
excellent
occasionally needs help
needs reminding
rarely occasionally
excellent
needs help frequently always works well
has great difficulty usually effective
rarely
maximum
usually
frequently good
usually
always
always
exceptional
(Revised 1/13)
Attention span
easily distracted usually good
Maturity in terms of age & grade
very immature above average
cannot be trusted usually trustworthy
Integrity and honesty Consideration of others Social adjustment with peers
normal
questionable highly developed
thoughtless usually considerate
seldom considerate always considerate
has serious problems has frequent minor problems has occasional minor problems very healthy
troublemaker usually good
Classroom conduct
insecure
Emotional stability
withdrawn pleasing
Personality
occasionally disrupts always good
overly tense
attention getter
overly aggressive unusually interesting
rarely laughs or smiles
Sense of humor
normal
good
usually
always
stable
delightful
needs much reassurance appears overly confident needs some support healthy self-image
Self confidence Cooperates with adults Cooperation of parents passive sociable stubborn irritable
somewhat mature very mature
a follower leads when put in position seeks opportunities and uses them well a natural leader
Leadership potential
occasionally distracted exceptionally good
rarely poor
sometimes fair
good
outstanding
Please check words which best describe this student
vivacious good-humored friendly well-liked belligerent forthright aggressive sullen persistent cheerful self-centered poised easily discouraged influential (wholesomely, unwholesomely)
aloof shy nervous
Other Comments :
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Teacher’s Signature_______________________________________________
Date________________________
Subject Taught_________________________________ School_________________________________________
