Students, please return to your counselor once form is completed. Form can be downloaded from www.dematha.org.
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Student Name: _____________________ Evaluation Period: _________________
Grade: 9 10 11 12 Requested by: _____________________
Subject / Teacher Name: _____________________________/____________________________________
What is the student’s approximate grade at this point? A B C D F (additional comments on back of sheet)
If C or below, please check all that apply: ___Homework incomplete ___Behavioral problem
Teacher Initials: ______ ___ Poor test / quiz grades ___ Attendance
Date: ___ /___ /___ Recent academic and/or behavioral progress noted? Yes or No
Subject / Teacher Name: _____________________________/____________________________________
What is the student’s approximate grade at this point? A B C D F (additional comments on back of sheet)
If C or below, please check all that apply: ___Homework incomplete ___Behavioral problem
Teacher Initials: ______ ___ Poor test / quiz grades ___ Attendance
Date: ___ /___ /___ Recent academic and/or behavioral progress noted? Yes or No
___ Other / Comments (please note on back of this sheet)
Subject / Teacher Name: _____________________________/____________________________________
What is the student’s approximate grade at this point? A B C D F (additional comments on back of sheet)
If C or below, please check all that apply: ___Homework incomplete ___Behavioral problem
Teacher Initials: ______ ___ Poor test / quiz grades ___ Attendance
Date: ___ /___ /___ Recent academic and/or behavioral progress noted? Yes or No
Subject / Teacher Name: _____________________________/____________________________________
What is the student’s approximate grade at this point? A B C D F (additional comments on back of sheet)
If C or below, please check all that apply: ___Homework incomplete ___Behavioral problem
Teacher Initials: ______ ___ Poor test / quiz grades ___ Attendance
Date: ___ /___ /___ Recent academic and/or behavioral progress noted? Yes or No
___ Other / Comments (please note on back of this sheet)
Subject / Teacher Name: _____________________________/____________________________________
What is the student’s approximate grade at this point? A B C D F (additional comments on back of sheet)
If C or below, please check all that apply: ___Homework incomplete ___Behavioral problem
Teacher Initials: ______ ___ Poor test / quiz grades ___ Attendance
Date: ___ /___ /___ Recent academic and/or behavioral progress noted? Yes or No