COUNSELOR’S RECOMMENDATION FORM
Name of Student:
Last First Middle Initial
Name of School: ________________________________________ Grade:____________
1. Which of the following best describes the student’s current or last academic program?
General College Preparatory Other Specify)________________
2. How would you rate this student in terms of aptitude and achievements?
Excellent Average Poor
Good Fair G.P.A.
3. How many days has the student been absent or tardy during the current school year?
5. What is the scheduled graduation date for the student’s class? _______________________
6. If the student is behind schedule please mark the appropriate box.
Will require at least one semester beyond his/her class scheduled graduation to
Is likely to be able to make up to the deficiency by taking extra load
Is likely to be able to make up the deficiency in summer school
In your recommendation, we want to know if you feel that this individual, given the
proper guidance and assistance, has the ability to do post-secondary work if given a
chance. We need to know any information you may have regarding the personal traits
of the individual.
PLEASE ATTACH THE FOLLOWING: Test Scores (Related Data)
Copy of Current Report Card
Signature of Counselor Date
Upward Bound Program Virginia State University
P.O. Box 9014 Petersburg, VA 23806
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