Student Reference Form
To parents of the enrolling student:
Please forward this form to your child’s previous or current school for completion. The form must be returned by theschool the student is attending and not by the parent.

To the school of the enrolling student:
The below-named student has applied for admission to EtonHouse International School, Tokyo. This reference is an
important part of the application and your assistance in providing a full and candid report will be appreciated.
Please e-mail this form directly to office@etonhouse.co.jp or by registered post to: Parent Liaison Office,EtonHouse International School Tokyo, 9-2-16 Akasaka, Minato-ku, Tokyo 107-0052.
Note: All information provided by you (the school) will be treated as “private and confidential” and this information will not be shared withthe parent/student without having obtained prior approval from you (the school). Please also refer to our school (EtonHouse InternationalSchool) PDPA available on our website.

PART 1: STUDENT DETAILS:
Student Name:

Current Grade/Year:

Last/Family NameFirst & Middle Name

Date of Birth:

Date of Enrolment:

Initial Grade/Year:(dd/mm/yyyy) to:(dd/mm/yyyy)

Name of School:
Attendance from:
Absent:

%

Late:

%

Early leave from school:%

Name ofTeacher:
How long have you known this student and in what context?

Suspension from school: Yes/NoClass:

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

I recommend this student (please ‘tick’ where applicable):
not recommend

with reservation

EtonHouse International School Tokyo
Office / Campus: 9-2-16 Akasaka, Minato-ku, Tokyo 107-0052
Tel: 03-6804-3322 Fax: 03-6804-3323
E-mail: office@etonhouse.co.jp Website: www.etonhouse.co.jp/

strongly recommendenthusiastically

PART 2: STUDENT STUDY SKILLS AND ABILITY:
Social / Emotional Development

No basis forjudgment

Needs
development

Age appropriate

Exceeds age
expectations

No basis forjudgment

Needs
development

Age appropriate

Exceeds age
expectations

No basis forjudgment

Needs
development

Age appropriate

Exceeds age
expectations

Uses taught social skills
Cooperates
Shares well
Follows directions
Respects classroom routines
Initiates play activities
Is imaginative
Is curious
Contributes appropriately to discussions
Uses materials purposefullyWorks independently
Physical Development
Small muscle control and coordination
Large muscle control and coordination
Speech development
Stamina
Learning and Academic Skills
Application/Effort
Is attentive
Listens in a group
Settles and focuses on one task
Completes tasks
Exhibits problem-solving abilities
Level of verbal English
Expresses thoughts well
Reading: decoding skills
Reading: comprehension skills
Writing skills

EtonHouse International School Tokyo
Office / Campus: 9-2-16 Akasaka, Minato-ku, Tokyo 107-0052
Tel: 03-6804-3322 Fax: 03-6804-3323
E-mail: office@etonhouse.co.jp Website: www.etonhouse.co.jp/

PART 3: PLEASE RATE THE CHILD ON OVERALL SCHOOL READINESS FOR:
1. Language development:

Age appropriate

Advanced

DelayedAge appropriate

Advanced

DelayedAge appropriate

Advanced

DelayedAge appropriate

Advanced

DelayedAge appropriate

Advanced

DelayedWhat is the child’s first language (mother tongue):
2. Reading readiness:
Current reading programme:

3. Mathematics readiness:
Current mathematics programme:

4. Motor development:
Comment:

5. Social development:
Comment:

6. Are there any special educational or medical needs identified for the student? Please write the name of
the identified special educational or medical need/s and any provisions the school has made.

Thank you for taking the time to complete our student reference. Should you wish to make any morecomments or have any questions please contact our Parent Liaison Office on +81 3 68304 3322 or email
us at office@etonhouse.co.jp

Teacher’s Signature

Date

Principal’s Name & Signature
School Stamp:

EtonHouse International School Tokyo
Office / Campus: 9-2-16 Akasaka, Minato-ku, Tokyo 107-0052
Tel: 03-6804-3322 Fax: 03-6804-3323
E-mail: office@etonhouse.co.jp Website: www.etonhouse.co.jp/Date