TGL Student Referral Form 2021-2022
This form is to be completed by School Staff, Community Members, or Parents who would like to refer a student to participate in the Gentlemen's League for the 2021-2022 School year. More information about The Gentlemen's League can be found by visiting: www.thegentsleague.org. Email a.moss@thegentsleague.org if you have any questions.
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Student's Name *
Student's Grade *
Required
Referred By (Name) *
Parent Name and Contact Number *
Parent's Email
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?
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
School *
What is the name of the school in Memphis, TN that your son attends?
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