Secondary School Report Form
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1Secondary School Report
To the Applicant
After printing this form and completing the applicant questions below, give this form to your secondary school counselor. Please also give
the counselor a stamped envelope addressed to Baker University, Office of Admission, PO Box 65 Baldwin City, KS 66006-0065.
Legal name ___________________________________________________________________________________________________
Last/Family/Sur (Enter name exactly as it appears on official documents.)
First/Given
Middle (complete)
Jr., etc.
Birth date _____________________________ Social Security # ____________________________
___Female ___Male
mm/dd/yyyy
(Optional)
Address _______________________________________________________________________________________________________
Number & Street
Apartment #
City/Town
State/Province
Country
ZIP/Postal Code
School you now attend ___________________________________________________________________________________________
Important privacy note: By signing this form, I authorize all schools that I have attended to release all requested records covered under the Family
Educational Rights and Privacy Act (FERPA) so that my application may be reviewed by Baker University. I further authorize the admission officers
reviewing my application to contact officials at my current and former schools should they have questions about the school forms submitted on my behalf.
Required signature ___________________________________________________________________________ Date _________________________
To the Secondary School Counselor
Attach applicant’s official transcript, including courses in progress, a school profile, and if possible any ACT or SAT results. Be sure to
sign below.
Counselor’s name (Mr./Ms./Dr., etc.) _______________________________________________________________________________
Please print or type
Title ____________________________________________________ School _______________________________________________
School address _________________________________________________________________________________________________
City/Town
State/Province
Country
ZIP/Postal Code
Counselor’s phone (______)__________________________________ Counselor’s fax (_______)_______________________________
Area Code
Number
Ext.
Area Code
Number
Ext.
Secondary school CEEB/ACT code _________________ Counselor’s email ________________________________________________
Student Information
Cumulative GPA ______ on a _____ scale, covering a period from ________ to ________
___Weighted ___Unweighted
mm/yyyy
mm/yyyy
Class rank _________ Class size _________ Graduation date _________
mm/dd/yyyy
Percentage of graduating class immediately attending _______ four-year ______ two-year institutions.
What are the first words that come to your mind to describe this student? ___________________________________________________
___
Check here if you would prefer to discuss this applicant over the phone with the Admission Office.
th
1. Has the applicant ever been found responsible for a disciplinary violation at your school from 9
grade (or the international equivalent)
forward, whether related to academic misconduct or behavioral misconduct that resulted in the applicant’s probation suspension,
removal, dismissal or expulsion from your institution? ___ Yes ___No
2. To your knowledge, has the applicant been adjudicated guilty or convicted of a misdemeanor, felony or other crime? ___Yes ___No
Note that you are not required to answer “yes” to this question or provide an explanation if the criminal adjudication or conviction has
been expunged, sealed, annulled, pardoned, destroyed, erased, impounded or otherwise ordered to be kept confidential by a court.
If you answered yes to either or both question, please attach a separate sheet of paper to give the approximate date of each incident and
explain the circumstances.
I recommend this student: ___No basis ___With reservation ___Fairly strongly ___Strongly ___Enthusiastically
Signature ______________________________________________________________________________ Date __________________
mm/dd/yyyy
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