SECTION 4: COUNSELOR RECOMMENDATION FORM
Please note that a student’s application will not be processed until all information is received. If a question does not apply to the student, write N/A (not applicable). Please contact Brenda Gatlin, HUB Academic Dean (313.715.4107) with any questions.
Student Name
*
First Name
Last Name
Current School
*
Current Grade
*
Current GPA
*
Your Name
*
First Name
Last Name
Position/Title
*
1. Does the student have an IEP and/or BIP? If so, please state his/her restrictions or attach a copy (please indicate if IEP/BIP is attached in the space below). Does the student have any physical limitations? If so, please describe:
*
2. Has the student had any discipline and/or attendance issues? If so, please explain:
*
3. Please identify the student’s major needs for academic/social enrichment? (check all that apply)
Reading (Oral Fluency, Comprehension)
Writing Ability
Math (Foundation, Computation)
Science
Social Sciences
Verbal/Oral Communication
Study Skills
Test-Taking
Self-Image
Group Relations
4. Does this student have academic potential for post‐secondary education pursuits?
Yes
No
5. Do you recommend this student to participate in Horizons‐Upward Bound?
*
Yes
No
6. Statement of support:
*
7. Please attach a copy of the student's transcripts. Also, please attach I-Ready results.
Transcripts
*
Most recent standardized test results. (PSAT or SAT)
Most recent standardized I-Ready Math test results.
Most recent standardized I-Ready Reading test results.
Counselor/Designated School Personnel Signature
*
You may use your mouse, touchpad, touchscreen, or cursor to sign
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Date
*
-
Month
-
Day
Year
mm-dd-yyyy
Phone #
*
(999)999-9999
Email
*
example@example.com
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