Note to student: Please complete the information requested in Student Data below and give this form to an academic teacher (English,
math, social studies, science, foreign language) or your school/college counselor.
Student Data
First Name__________________________________________ Last Name
________________________________________________________
Address __________________________________________________________________ Apt _____ Birth date (optional) _______________
City, state, zip _____________________________________________________ Campus applying to ________________________________
Student’s signature _______________________________________________________________ Date ________________________________
Teacher or Counselor Data:
Recommender name and title
__________________________________________________________________________________________
Subject taught _________________________________________________________________________________________________________
Recommender phone ________________________________________Recommender email _____________________________________
Relationship to Student
Approximately how long have you known this student?_______ Years
When did you have this student in your class(es)
_________________________________________________________________________
________________________________________________________________________________________________________________________
What class(es) did you teach this student?
_______________________________________________________________________________
________________________________________________________________________________________________________________________
Academic Preparedness of the Student
No basis to judge Below average Average Above average Excellent
Knowledgeinproposedeldofstudy
Ability to grasp new concepts
Written expression
Oral expression
Work consistent with ability
Mathematical and logical thought
How did this student advocate and/or take ownership for their learning experience?
______________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
In your experience with this applicant, what suggests that the student is academically prepared for college?
_______________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Aretherespecicobstaclesthestudentmightfacetocollegesuccess? __________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please provide any additional relevant information or comments
_________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Special Note: My school district does not allow me to complete this form. (Please provide signature below).
Recommender signature
__________________________________________________________ Date _______________________________
Recommendation for Undergraduate Admission
(Compare with other students you have taught):
October 2015