EmailMe Form - Northlake Christian Kindergarten Referral

Student's Name *

First Last

Student's Current School *

Student's Current Grade *

School's Phone

### - ### - ####

TO THE TEACHER:

We appreciate your cooperation in completing this form. It will be used, along with other items of assessment, to determine readiness
for kindergarten. This form gives us the opportunity to get to know the child with the full understanding that young children are constantly changing
and maturing. Please check the boxes below. We also welcome your comments in each area.

Name of Teacher Completing this form *

First Last

Teacher's Email (in case we have further questions)

For how long have you known this applicant? *

Pre-Academic Skill Development

	Usually	Sometimes	Seldom	No opportunity to observe
Is attentive	1	2	3	4
Listens in a group	1	2	3	4
Contributes to a group discussion	1	2	3	4
Joins in group song/recitation	1	2	3	4
Follows directions	1	2	3	4
Works cooperatively	1	2	3	4
Completes tasks	1	2	3	4
Able to focus on one task	1	2	3	4
Respects classroom routines	1	2	3	4
Accepts constructive criticism	1	2	3	4
Is a self-starter	1	2	3	4
Exhibits problem solving abilities	1	2	3	4
Expresses ideas well	1	2	3	4

SOCIAL DEVELOPMENT Evaluate the following statements.

	Usually	Sometimes	Seldom	No opportunity to observe
Can be a friend	1	2	3	4
Relates positively with adults	1	2	3	4
Plays alone happily	1	2	3	4
Cooperates in play	1	2	3	4
Shares well	1	2	3	4
Is imaginative	1	2	3	4
Prefers to lead	1	2	3	4
Prefers to follow	1	2	3	4
Uses materials purposefully	1	2	3	4

Physical Development

Small muscle control/coordination *

Additional Comments

Large muscle control/coordination *

Additional Comments

Speech Development (Articulation) *

Additional Comments

Please identify any special needs, including auditory and visual development.

Additional Academic Skills

Please describe the applicant’s development in:

BEGINNING READING SKILLS:

BEGINNING MATH SKILLS:

Description of Child: Please include outstanding qualities, as well as areas which indicate a need for further development for kindergarten.

I recommend this student: *

Any additional Comments we need to know about this student:

Thank you so much for taking the time to complete this form. Your assistance helps us immensely!

This form will be emailed directly to the Office of Admissions at Northlake Christian School.