Secondary School Report Form
SECTION I (to be completed by student)
Student Name____________________________________________________________________________________________
Last
First
MI
Address ________________________________________________________________Date of Birth
_______________________________________________________________________ Phone (
______/______/______
) ____________________
E-mail Address ____________________________________________________________________________________________
Early Decision
I am applying for:
Early Action
I recognize the confidential nature of this document and I
Regular Decision
do
do not
Other:____________________________
waive my right to access.
Student’s Signature________________________________________________________ Date_____________________________
SECTION II (to be completed by school counselor––include information only if it is not included in other student documents)
High School
WINSTON CHURCHILL HIGH SCHOOL
Address
11300 Gainsborough Road, Potomac, MD 20854
Phone
(301) 469-1220
Counselor’s Name
High School CEEB
210839
Fax (301) 469-1663
_________________________________________________
Title
School Counselor
E-mail Address ___________________________________________________________________
Percentage of class attending: Four-Year ____92%____ Two Year __5%____ institutions.
Grading scale 
4.0 100
Other
Passing Grade is _______D______
Student’s GPA __________________
Weighted [ ]
GPA includes (check all that apply):
9th Grade _X__ 10th Grade _X__ 11th Grade _X__ 12th Grade ___
Unweighted [ ]
Student rank ___N/A______in a class of _534_____ as of: 9th Grade___ 10th Grade __ 11th Grade ___12th Grade ___
[X] WE DO NOT RANK. See “Profile of the Class of 2014” for grade distribution of cumulative averages.
Is the student’s course selection: 
Most Demanding Very Demanding DemandingAverage 
Below Average
SENIOR YEAR COURSES:
First Term:
Course
___On current transcript___________
Second Term:
Grade
_____
Course
_____On current transcript__________________
Grade
_____
_________________________________
_____
_______________________________________
_____
_________________________________
_____
_______________________________________
_____
_________________________________
_____
_______________________________________
_____
_________________________________
_____
_______________________________________
_____
_________________________________
_____
_______________________________________
_____
(See reverse side.)
SECTION III (to be completed by school counselor)
Please comment on the following items which reference the student’s ability and character. Attach additional pages if more space is needed.
(A recommendation letter may replace Section III.)
Academic Ability:
Personal Character:
Is the academic record of this student an accurate indication of the student’s ability?
If not, please describe the circumstances.
Counselor Statement:
Yes

No
Please see the counselor’s letter of recommendation.
___________________________________________________________________________________________________________
Thank you.
Counselor’s Signature_________________________________________________________ Date ___________________________