TGL Student Referral Form 2018-2019
This form is to be completed by School Staff or Community Members who would like to refer a student to participate in the Gentlemen's League.
Student's Name *
Your answer
Student's Grade *
Your answer
School *
Referred By (Staff Name) *
Your answer
The child is being referred for assistance in the following areas (check all that apply): *
Required
What particular interests, either in school or out, do you know of that the child has?
Your answer
On a scale of 1–10 (10 being highest) rate the student’s level of:
1 (lowest)
2
3
4
5 (neutral)
6
7
8
9
10 (highest)
Academic performance 
Social skills 
Self-Esteem
Family support 
Communication Skills
Attitude about school/education 
Peer Relations
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