Student                                                                                                                  Grade Entering
Parent’s Signature                                                                                             Date
Parent Instruction:             Complete the above information on all form.  Please give this form to the student’s recent Dean of Students,
Administrative Official or the person holding the student’s disciplinary records.  By doing so, you understand that the
information requested is confidential and that you waive the right to read this reference.
Administrative Official:     This student is seeking admission to The Beverly Institute.  The student may not be admitted until this confidential
information has been received.  When you have completed the form, please fax it directly to the Registrar. Please do not
return this form to the parent.  Thank you for your promptness in this matter.
                                              [    ] Please check here if you wish to discuss this student personally rather than complete this
form.  Sign the form at the bottom and note your telephone number.  The Admissions Director will call you.
Quality
Excellent
Good
Average
Fair
Poor
Unknown
Responsibility/ Reliability
Personal & Moral Integrity
Respect for Authority
Honesty
Attitude
Cooperation
Leadership
Emotional Stability
Orderliness
Initiative
Appearance/ Cleanliness
Do you know of any specific discipline problem the student has?
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Would you accept the applicant’s as a returning student in your school next year?              Yes         No
Why? _________________________________________________________________________________
Addition Comments: (Use the back of this page if more space is needed) ___________________________
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In what capacity have you known the student? __________________________ How Long? ____________
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Signature                                                                               Title
______________________________________       
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School                                                                                    Phone Number
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Address