CURRENT TEACHER QUESTIONNAIRE

(Grades PreK – 5)

To be completed by Parent:

Name of Student:

Current School:Current Grade:

I hereby waive my right to access this recommendation and authorize the below-named person to provide an evaluation and all relevant information to the school for purposes of my student’s application to attend Summit Academy.

Signature of parent or legal guardian:Date:

To the Teacher: We appreciate your cooperation and candor in completing this form. It provides one way of getting to know the student and is reviewed with the full awareness that students are constantly changing and developing. Please note that we place particular value on your observations of academic ability, motivation, classroom behavior, and your descriptive comments in each area. Your insights will be used solely to help inform a thoughtful admission decision which will result in the best placement for each applicant. Please return this completed form in the provided self-addressed, stamped envelope as soon as possible.

Name of Teacher completing form:Date:

How long have you known this student?

1. In your opinion, what do you see as the major weaknesses which are interfering with this child’s learning?

2. Describe this child’s strengths.

3. To what degree is this child’s behavior a problem in the classroom?

4. Indicate how often this child displays these behaviors. (Please check the best descriptor)

Consistently / Usually / Occasionally / Seldom
Written papers show frequent erasures, an inability to stay on the line, and/poor spacing
Shows inaccuracy when counting
Shows difficulty in counting
Shows difficulty in discriminating similar vowel and consonant sounds
Has trouble blending sounds and/or syllables into a word
Drawings are very immature, lacking detail
Shows difficulty with letter and numeral formation
Frequently gets confused in following directions
Unable to follow and understand classroom discussions
Generally inattentive
Does not appear to understand vocabulary expected at his/her age
Uses a limited speaking vocabulary with few precise descriptive words
Seems to have difficulty communicating his ideas and searches for words to express himself
Shows considerable difficulty relating ideas in a logical sequence
Daydreams and has difficulty finishing tasks
Becomes frustrated very easily and may yell, scream, cry or hit when frustrated
Is unable to compete in athletic games
Social competence is below level expected

Comments:

5. Please rate the following parent and family information(Please check best descriptor)

Consistently / Usually / Occasionally / Seldom
Supportive of the student’s experience
Supportive of your school’s programs/routines
Supportive of you as a teacher
Perception of the student compatible with the school’s understanding of the student.
Responsive to suggestions/guidance
Realistic in setting educational goals
Make school a priority as exhibited by student attendance

Comments:

6. Please comment on this student’s ability to meet the expectations of your school. Have you adjusted your program to accommodate the needs or abilities of this student?

Your Name (Print):

Signature:Date:

School Name:

School Address:

School Telephone:Fax Number:

Email:

Thank you for filling out theCurrent Teacher Questionnaire.

Summit Academy

Attn: Admissions Office

11508 Main Street

Louisville, KY 40243

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