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.
FOR THE STUDENT
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 ofcers reviewing my application, including seasonal staff employed for the sole purpose of evaluating applications, to contact ofcials
at my current and former schools should they have questions about the school forms submitted on my behalf.
By signing below, I agree to the preceding statement.
I waive my right to access these records, and I understand I will never see this form or any other recommendations submitted by me
or on my behalf.
Required Signature Date
Student Name SSN (optional)
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
FOR THE COUNSELOR
High School High School CEEB
Address
City State/Province ZIP/Postal Code
Phone Fax
Counselor’s Name Title
Email
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
Please list the applicant’s senior-year courses indicating term/marking period (include course level – AP, honors, IB, etc.).
