Keimei Gakuen Elementary Junior & Senior High School
5-11-15, Haijima-cho, Akishima-shi, Tokyo, 196-0002, JAPANTel. 042-541-1003・Fax 042-546-5881

Home page http://www.keimei.ac.jp

Recommendation Form
Student:
Please type or print your name and parents name in the space below and give this form to your principal, Counselor, English
teacher, or math teacher.
Name of Student:

Grade:Name of Parent:
Principal /Counselor/teacher:This recommendation will remain confidential and will not become part of the student’s permanent record. If you prefer, you
may type and attach your responses on separate sheets of paper. When you have completed the form, please make a photocopy,
put the original in the sealed envelope, and hand it to the student. Thank you for your cooperation and candor.

Name and Title of Principal/ Counselor/Teacher:Academic and Personal Qualities
How long have you known the student?
How many students are in the applicant’s entire grade?
What are the first three words that come to mind to describe this student?
Has the student ever been a disciplinary problem? If yes, briefly explain, noting any disciplinary action taken.

Has the student advanced to the next grade annually? If no, please explain.
How would you rank the student in the following areas compared with students of the same age?
Truly Outstanding(Top 5%)

Excellent

GoodAverage

Below Average

Character□

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Intellectual Curiosity□□□□□

Potential for Growth□

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Summary Evaluation

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What are the student’s strengths?

In which areas does this student need improvement?

Does the student attend class regularly?

□Yes□NoIs there a problem with tardiness?

□Yes□NoIf so, please explain:

How well does the student accept advice or criticism?
If the student handed in a paper late, it would probably be because the student:□Procrastinates□Strives for perfection of expression□Has many other activities□Lost the rough draft

Which words best describe the student’s thinking?
□Imitative□Independent□Student’s work is never late
□Other, please explain□Creative□OtherDoes this student have any particular interests or abilities you would like to share with us?

Please check if this student is participating in any programs or services listed below.
Behavior Management
Occupational Therapy
IEP
ESOL/ESL (English as a Second Language/English for Speakers of Other Languages)
Remedial/Learning Support
Gifted/Gifted and Talented
Speech/Language Therapy
Individual/Family Counseling
Other ()
Describe any of the programs checked above. (Attach a separate sheet if necessary.)

Within your range of experiences, how would you rate the student?
□ Truly Outstanding(Top 5%)□ Excellent□ Good□ Average□ Below Average

Is there any other information that would be helpful to us in evaluating the ability of this student to perform at Keimei Gakuen?

Parent/School Relationship
Parents are important part of our relationship with the student. Please share with us any thoughts you have regarding thisfamily.

Are you aware of any family circumstances that affect the student’s life at school?

Which word(s) best describe the parents in regard to their child?
□Supportive□ Demanding□Controlling□ Indifferent□ Other

Additional Comments:
If we have additional questions, may we call you?
If yes, phone number ( include area code):
Most convenient time to call is:
SignatureThank you for your time and expertise in completing this form.

□YesDate□ No