Child Reference Form - School Please answer these questions to the best of your ability. This information will be kept confidential. Child's name* First Last Date of birth* Date Format: MM slash DD slash YYYY Reference's name* First Last Your position*School name*I know this child*Very wellWellA bitNot very wellWould you recommend this child for our programs?*YesNoIf so, how do you think he would most benefit from being in the program?*What qualities in a mentor do you think would be most helpful for this child?*What are the child’s interests?*What are this child’s strengths and weaknesses in relating to adults?*What are this child’s strengths and weaknesses in relating to peers?*Please describe any behavioural or emotional difficulties this child may be having and the best ways you have found to deal with them:*How eager is this child to try new things?*Does this child seem interested in school?*Is this child functioning near or at his grade level in academic subjects?*To your knowledge, does this child seem to have a good relationship with his guardian?*Has the guardian been supportive of your relationship with this child?*On a scale of 1-5, where 1 = not well, and 5 = very well, rate the following questionsHow well is this child able to concentrate on academic subjects?*12345How well does this child participate in non-academic subjects?*12345How well does this child get along with his/her peers?*12345How well does this child get along with adults?*12345How well does this child follow directions?*12345Are there other professional resources (school counselor, psychologist, social worker, etc.) working with this family? Please give names and contact numbers if you know them.*By checking yes below, you agree that all the information above is true.* Yes
