Secondary School Report
INSTRUCTIONS: Counselors, please verify that the For the Student section is complete (if it is not, ask the student to provide the
missing information), ll out the For the Counselor section and forward this form, along with other supporting/attached documents,
to either individual or multiple schools to which this student is applying.
Important Privacy Note: By signing this form, I authorize all schools I have attended to release all requested records covered under the Federal
Educational Rights and Privacy Act (FERPA) so that my application may be reviewed by the institution(s) to which I am applying. I further authorize
the admission ofcers reviewing my application, including seasonal staff employed for the sole purpose of evaluating applications, to contact ofcials
at my current and former schools should they have questions about the school forms submitted on my behalf.
I waive my right to review or access letters and statements of recommendation on my behalf. Yes No
Required Signature Date
Student Name
Address Date of Birth (mm/dd/yyyy)
City State/Province ZIP/Postal Code
Country Phone Email
I am applying for: Early Decision Early Action Regular Decision Other
Please list the applicant’s senior-year courses indicating term/marking period (include course level – AP, honors, IB, etc.).
/ /
( ) –
High School High School CEEB
City State/Province ZIP/Postal Code
Phone Fax
Counselor’s Name Title
Percentage of class attending: Four-Year Two-Year institutions.
Grading Scale 4.0 100 Other Passing Grade Student’s GPA Weighted Unweighted
GPA includes (check all that apply): 9th Grade 10th Grade 11th Grade 12th Grade
Student rank in a class of as of: 9th Grade 10th Grade 11th Grade 12th Grade We do not rank
This student’s course selection is: Most Demanding Very Demanding Demanding Average Below Average
Type and number of courses offered at your school: AP IB Honors
Maximum number a student may take in a given year, if limited: AP IB Honors
Applicant is an IB Diploma candidate: Yes No Classes are taken on a block schedule: Yes No
Please answer the following questions.
Has the applicant been found responsible for a disciplinary violation at your school from 9th grade forward whether academic or behavioral, which
resulted in the applicant’s probation, suspension, removal, dismissal or expulsion from your school? Yes No
To your knowledge, has the applicant ever been convicted of a misdemeanor, felony or other crime? Yes No
If you answered yes to either or both questions, please explain the circumstances on the following page.
I recommend this student: Very Highly Highly Moderately With Reservations
Signature Date
Please rate your student compared to other students in his or her class.
Top 10% Above Average Average Below Average
Academic Achievements
Extracurricular Accomplishments
Personal Qualities and Character
Please expand on your student’s abilities, accomplishments and character in the space below – attach additional pages if needed.
OR simply attach a letter of recommendation you have already written, if you believe it adequately addresses this request.
Explanation of the applicant’s probation, suspension, removal, dismissal or expulsion from your school, if applicable:
Explanation of the applicant’s conviction of a misdemeanor, felony or other crime, if applicable: