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myLoyola
Request for Records
Please enter all required information.
Invalid text has been entered. Please correct all errors and click submit
*Student Name:
*Current School:
*Relationship to Student:
The items below ask for your sense of this student's emotional and social growth, intellectual development, and relationships within the school community. We understand the difficulty in making such an evaluation. Information on this form will remain confidential and will not be shared with parents. On behalf of this student, we thank you for your cooperation.
*How long have you known this candidate?
*My relationship has been that of:
Academic Qualities
*Academic Abilities
Outstanding
Good
Average
Below Average
No Basis to Judge
*Academic Achievement
Outstanding
Good
Average
Below Average
No Basis to Judge
*Self-Motivation
Outstanding
Good
Average
Below Average
No Basis to Judge
*Study Habits
Outstanding
Good
Average
Below Average
No Basis to Judge
*Intellectual Curiosity
Outstanding
Good
Average
Below Average
No Basis to Judge
*Ability to Work
Outstanding
Good
Average
Below Average
No Basis to Judge
*Participation in Discussions
Outstanding
Good
Average
Below Average
No Basis to Judge
*Writing Ability
Outstanding
Good
Average
Below Average
No Basis to Judge
*Oral Expression
Outstanding
Good
Average
Below Average
No Basis to Judge
*Follows Directions
Outstanding
Good
Average
Below Average
No Basis to Judge
*Uses Suggestions/Corrections
Outstanding
Good
Average
Below Average
No Basis to Judge
*Seeks Help When Needed
Outstanding
Good
Average
Below Average
No Basis to Judge
*Attention Span
Outstanding
Good
Average
Below Average
No Basis to Judge
*Please Select the Word that Help Describe the Applicant (hold down Control button to select multiple choices)
Aggressive
Anxious
Articulate
Cheerful
Disobedient
Easily Discouraged
Helpful
Follower
Perfectionist
Influential
Irritable
Manipulative
Organized
Confident
Over-Protected
Passive-Resistant
Self-Centered
Motivated
Shy
Responsible
Social
Self-Disciplined
Conscientious
Vivacious
Well-Liked
Positive Leader
Negative Leader
Honest
Personal Qualities
*Academic Ability
Outstanding
Good
Average
Below Average
No Basis to Judge
*Maturity
Outstanding
Good
Average
Below Average
No Basis to Judge
*Consideration for Others
Outstanding
Good
Average
Below Average
No Basis to Judge
*Peer Social Adjustment
Outstanding
Good
Average
Below Average
No Basis to Judge
*Self-Confidence
Outstanding
Good
Average
Below Average
No Basis to Judge
*Integrity
Outstanding
Good
Average
Below Average
No Basis to Judge
*Conduct
Outstanding
Good
Average
Below Average
No Basis to Judge
*Self-Control
Outstanding
Good
Average
Below Average
No Basis to Judge
*Parental Support
Outstanding
Good
Average
Below Average
No Basis to Judge
*Follows Directions
Outstanding
Good
Average
Below Average
No Basis to Judge
*Uses Suggestions/Corrections
Outstanding
Good
Average
Below Average
No Basis to Judge
*Seeks Help When Needed
Outstanding
Good
Average
Below Average
No Basis to Judge
*Attention Span
Outstanding
Good
Average
Below Average
No Basis to Judge
*Has the applicant been evaluated for any physical, emotional, or academic reasons?
Yes
No
Don't Know
*Is the applicant currently on medication or previously been on medication?
Yes
No
Don't Know
If yes, please explain:
*Have you observed any signs of learning differences?
Yes
No
Don't Know
*Is the applicant on an IEP or 504 education plan?
Yes
No
Don't Know
*Do you have any information that may be helpful in our evaluation of this student?
Yes
No
Don't Know
Please explain:
*Name of Person Completing Form:
*Position at School:
*Email Address:
Loyola Blakefield
500 Chestnut Ave. Towson, MD 21204
communications@loyolablakefield.org
(410) 823-0601
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