BREBEUF JESUIT PREPARATORY SCHOOL
APPLICATION FOR 75$16)(5 ADMISSION
Brebeuf Jesuit Preparatory School Mission Statement
Brebeuf Jesuit, a Catholic and Jesuit school, provides an excellent college preparatory education for a lifetime of service by
forming leaders who are intellectually competent, open to growth, loving, religious and committed to promoting
justice. Fostering a culture of understanding and dialogue, Brebeuf Jesuit seeks and welcomes students from diverse
religious, ethnic and socio-economic backgrounds. Students at Brebeuf Jesuit are called to discover and cultivate the fullness
of their God-given talents as a responsibility and as an act of worship.
APPLICATION PROCESS
1. COMPLETE THE APPLICATION FOR ADMISSION
(ONLINE APPLICATION AVAILABLE AT WWW.BREBEUF.ORG/ADMISSIONS)
MAIL TO: Brebeuf Jesuit Preparatory School
Attn: Admissions Office
2801 W. 86th Street
Indianapolis, IN 46268
2. SUBMIT THE FOLLOWING ITEMS
•
3. SUBMIT TWO RECOMMENDATION FORMS
• One from either an English OR
her
• One from either a Math OR Science teacher
4. INCLUDE A $50 NON-REFUNDABLE APPLICATION FEE (payable to Brebeuf Jesuit).
COMPLETED RECOMMENDATIONS ARE
PERSONNEL DIRECTLY TO THE ADMISSIONS OFFICE AT BREBEUF JESUIT PREPARATORY SCHOOL AT
THE ADDRESS ABOVE.
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
PAGE 4
STUDENTS AND PARENTS NEED TO PROVIDE RESPONSES TO THE FOLLOWING QUESTIONS.
THESE RESPONSES MUST BE TYPED ON A SEPARATE SHEET(S) OF PAPER. PLEASE SUBMIT YOUR
RESPONSES TO THE ADMISSIONS OFFICE ALONG WITH THIS APPLICATION.
APPLICANT/STUDENT’S ESSAY
Brebeuf Jesuit Preparatory School
Application for 7UDQVIHU Admission
Why would Brebeuf Jesuit be the best school for you, and what do you have to offer Brebeuf Jesuit?
OPTIONAL SCHOLARSHIP ESSAY
ALL STUDENTS ARE INVITED TO SUBMIT AN ESSAY FOR CONSIDERATION FOR SCHOLARSHIPS BY THE BREBEUF JESUIT
SCHOLARSHIP COMMITTEE. AWARDS ARE GIVEN TO INCOMING FRESHMAN STUDENTS WHO DEMONSTRATE GOOD CHARACTER, ACADEMIC TALENT, AND FINANCIAL NEED. (MUST COMPLETE PSAS FORM)
Please describe your special gifts and passions, which you hope to cultivate while a student at Brebeuf Jesuit.
STUDENT INFORMATION
APPLICANT’S NAME ______________________________________________________________________________________________________________
LAST
FIRST
MIDDLE
GENDER ❑ FEMALE ❑ MALE PREFERRED FIRST NAME__________________________________________________________
MAILING ADDRESS________________________________________________________________________________________________________________
ADDRESS ATE PARENT’S LETTER OF RECOMMENDATION
HOME PHONE_____________________________________________ PLEASE WRITE A LETTER OF RECOMMENDATION TO THE ADMISSIONS COMMITTEE FOR YOUR SON OR DAUGHTER. THIS
RECOMMENDATION SHOULD INCLUDE A STATEMENT ON WHY YOU BELIEVE BREBEUF JESUIT AS A FAITH-BASED SCHOOL
AND YOUR STUDENT WOULD MAKE A GOOD MATCH, AND HOW YOU EXPECT YOUR SON OR DAUGHTER TO BENEFIT
FROM A BREBEUF JESUIT EDUCATION. PLEASE USE A SEPARATE SHEET OF PAPER
STUDENT CELL PHONE____________________________________________
STUDENT EMAIL______________________________________________________ DATE OF BIRTH____________________________________
U.S. CITIZEN? ❑ YES ❑ NO
(IF NO, ATTACH EXPLANATION OF STATUS)
RACE/ETHNICITY
❑AMERICAN INDIAN ❑ASIAN ❑BLACK / AFRICAN AMERICAN ❑CAUCASIAN / WHITE ❑ HISPANIC
❑PACIFIC ISLANDER ❑MULTIRACIAL, PLEASE SPECIFY______________________
❑ OTHER: PLEASE SPECIFY_________________________
RELIGION
❑ CATHOLIC ❑ HINDU ❑ JEWISH ❑ MUSLIM ❑OTHER:______________________________________________
EDUCATIONAL HISTORY
CURRENT GRADE_________
I HEREBY CERTIFY THAT THE INFORMATION ON THE APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. I FURTHER UNDERSTAND THAT IF ANY INFORMATION IS FALSIFIED IT MAY RESULT IN THE DENIAL OF
ADMISSION TO BREBEUF JESUIT.
________________________________________________________________________________________________________________________________
PRINTED NAME OF APPLICANT DATE
_______________________________________________________________________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN PRINTED NAME OF PARENT OR GUARDIAN DATE
________________________________________________________________________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN PRINTED NAME OF PARENT OR GUARDIAN ❑ NONE
PARISH OR PLACE OF WORSHIP________________________________________
NAME OF CURRENT SCHOOL______________________________________________________________
PREVIOUS SCHOOL (IF LESS THAN 2 YEARS IN CURRENT SCHOOL)____________________________________________________________________
APPLICANT/PARENT ACKNOWLEDGMENT & SIGNATURES
SIGNATURE OF APPLICANT ❑ PROTESTANT DATE
HAVE ANY SPECIAL CIRCUMSTANCES AFFECTED THE APPLICANT’S PERFORMANCE IN SCHOOL?
IF YES, PLEASE ATTACH AN EXPLANATION ON A SEPARATE SHEET.
❑ YES ❑ NO
HAS THE APPLICANT EVER BEEN SUSPENDED, EXPELLED, OR ASKED TO WITHDRAW FROM ANY SCHOOL? ❑ YES ❑ NO
IF YES, PLEASE ATTACH AN EXPLANATION ON A SEPARATE SHEET.
❑ APPLYING FOR THE LEARNING CENTER (SEE NOTE BELOW)
The Learning Center provides academic support services for students with a diagnosed learning difference. Applicants to the Learning Center must provide a
psychoeducational evaluation that has been completed within the last two years. All materials are kept confidential. Visit www.brebeuf.org/learningcenter for more
information.
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
PAGE 2
FAMILY INFORMATION
WITH WHOM DOES
THE APPLICANT LIVE?
PAGE 3
CURRICULAR AND CO-CURRICULAR INFORMATION—TO BE COMPLETED BY THE APPLICANT
❑Father & Mother (same home) ❑ Father & Stepmother
❑Father & Mother (different homes) ❑ Mother & Stepfather ❑Father only
❑Mother only
❑Legal Guardians(s)
❑OTHER:____________________
PARENT A ______________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER_____________
LAST RELATIONSHIP TO APPLICANT ❑ FATHER
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
FIRST M.I.
❑ MOTHER ❑ STEPFATHER ❑ STEPMOTHER
❑ GUARDIAN ❑OTHER________________
PLEASE LIST CO-CURRICULAR ACTIVITIES AT SCHOOL OR IN THE COMMUNITY IN WHICH YOU HAVE BEEN INVOLVED DURING 6TH, 7TH
AND/OR 8TH GRADE. PLEASE NOTE ANY LEADERSHIP POSITIONS AND/OR HONORS RECEIVED.
ACTIVITY POSITIONS HELD/HONORS RECEIVED YEARS OF PARTICIPATION
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
HOME ADDRESS (IF DIFFERENT FROM APPLICANT) CITY STATE ZIP
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
HOME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
EMPLOYER OCCUPATION/TITLE WORK PHONE NUMBER
________________________________________________________________________________________________________________________________
_________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER ❑ Brebeuf Jesuit Grad (YEAR_______)
NAME OF STEPPARENT IN SAME HOUSEHOLD AS PARENT A (IF APPLICABLE)
________________________________________________________________________________________________________________________________
EMPLOYER/TITLE WORK PHONE CELL PHONE EMAIL
PARENT B______________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER_____________
LAST FIRST M.I.
RELATIONSHIP TO APPLICANT ❑ FATHER ❑ MOTHER ❑ STEPFATHER ❑ STEPMOTHER
❑ GUARDIAN
PLEASE LIST ANY COMMUNITY SERVICE AND/OR RELIGIOUS ACTIVITIES IN WHICH YOU HAVE BEEN INVOLVED DURING 6TH, 7TH
AND/OR 8TH GRADE. PLEASE NOTE ANY LEADERSHIP POSITIONS AND/OR HONORS RECEIVED.
ACTIVITY POSITIONS HELD/HONORS RECEIVED YEARS OF PARTICIPATION
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
❑ OTHER______________
________________________________________________________________________________________________________________________________
HOME ADDRESS (IF DIFFERENT FROM APPLICANT) CITY STATE ZIP
________________________________________________________________________________________________________________________________
HOME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS
________________________________________________________________________________________________________________________________
EMPLOYER OCCUPATION/TITLE WORK PHONE NUMBER
_________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER ❑ Brebeuf Jesuit Grad (YEAR_______)
NAME OF STEPPARENT IN SAME HOUSEHOLD AS PARENT A (IF APPLICABLE)
________________________________________________________________________________________________________________________________
EMPLOYER/TITLE WORK PHONE CELL PHONE EMAIL
SIBLINGS
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
Brebeuf Jesuit Tradition
Please list any other relatives who have graduated from Brebeuf Jesuit or any other Jesuit high school, college or university.
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
PLEASE INDICATE THE CO-CURRICULAR ACTIVITIES IN WHICH YOU HAVE AN INTEREST IN PARTICIPATING DURING HIGH SCHOOL.
CO-CURRICULAR ACTIVITIES
❑ ACADEMIC SUPER BOWL
❑GLEE CLUB
❑ANIME CLUB
❑INDIANA UNIVERSITY HONORS PROGRAM
❑ART CLUB
❑IMPROV COMEDY CLUB
❑ASIAN CLUB
❑INTRAMURAL SPORTS
❑BLACK ROBE RUNNING CLUB
❑CELTIC CLUB
❑BLACK STUDENT UNION
❑JEWISH STUDENT UNION
❑BRAIN GAME
❑KENYA HELP US? CLUB
❑BREBEUF CLASSICAL CLUB
❑LEADERSHIP INITIATIVES
❑CHEM TEAM
❑LIFE CLUB
❑CHESS CLUB
❑MANITOU: LITERARY MAGAZINE
❑COEXIST CLUB
❑MATH COMPETITIONS
❑CONSERVATION CLUB
❑MODEL U.N.
❑DECA
❑NATIONAL HONOR SOCIETY
❑FEDERAL & ECON CHALLENGE
❑OUTDOOR CLUB
❑FRENCH CLUB
❑PACT (PEERS AGAINST CANCER TOGETHER)
❑RAK (RANDOM ACTS OF KINDNESS)
❑SCIENCE OLYMPIAD
❑SOFA (SERVICE ORIENTED FOOD APPRECIATION)
❑SPANISH CLUB
❑SPEECH & DEBATE
❑STRAP (STUDENTS TOGETHER AGAINST POVERTY)
❑STUDENT COUNCIL
❑SWEET HARMONY/MANIC BARCODE CHOIRS
❑THE JUSTICE LEAGUE (FORM. AMNESTY INT’L)
❑THEATRE
❑TIMMY FOUNDATION
❑YOUNG DEMOCRATS
❑YOUNG LIFE
❑YOUNG REPUBLICANS
IHSAA & CLUB SPORTS
BOYSGIRLS
❑BASEBALL
❑LACROSSE (CLUB)
❑BASKETBALL
❑BASKETBALL
❑SOCCER
❑BOWLING (CLUB)
❑BOWLING (CLUB)
❑SWIMMING
❑CHEERLEADING
❑CREW
❑TENNIS
❑CREW
❑CROSS COUNTRY
❑TRACK & FIELD
❑CROSS COUNTRY
❑FOOTBALL ❑VOLLEYBALL (CLUB)
❑CREW
❑GOLF
❑WRESTLING
❑DANCE
❑HOCKEY (CLUB) ❑DANCE
❑GOLF
❑LACROSSE (CLUB)
❑SOCCER
❑SOFTBALL
❑SWIMMING
❑TENNIS
❑TRACK & FIELD
❑VOLLEYBALL
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
PAGE 2
FAMILY INFORMATION
WITH WHOM DOES
THE APPLICANT LIVE?
PAGE 3
CURRICULAR AND CO-CURRICULAR INFORMATION—TO BE COMPLETED BY THE APPLICANT
❑Father & Mother (same home) ❑ Father & Stepmother
❑Father & Mother (different homes) ❑ Mother & Stepfather ❑Father only
❑Mother only
❑Legal Guardians(s)
❑OTHER:____________________
PARENT A ______________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER_____________
LAST RELATIONSHIP TO APPLICANT ❑ FATHER
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
FIRST M.I.
❑ MOTHER ❑ STEPFATHER ❑ STEPMOTHER
❑ GUARDIAN ❑OTHER________________
PLEASE LIST CO-CURRICULAR ACTIVITIES AT SCHOOL OR IN THE COMMUNITY IN WHICH YOU HAVE BEEN INVOLVED DURING IN.
PLEASE NOTE ANY LEADERSHIP POSITIONS AND/OR HONORS RECEIVED.
ACTIVITY POSITIONS HELD/HONORS RECEIVED YEARS OF PARTICIPATION
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
HOME ADDRESS (IF DIFFERENT FROM APPLICANT) CITY STATE ZIP
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
HOME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
EMPLOYER OCCUPATION/TITLE WORK PHONE NUMBER
________________________________________________________________________________________________________________________________
_________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER ❑ Brebeuf Jesuit Grad (YEAR_______)
NAME OF STEPPARENT IN SAME HOUSEHOLD AS PARENT A (IF APPLICABLE)
________________________________________________________________________________________________________________________________
EMPLOYER/TITLE WORK PHONE CELL PHONE EMAIL
PARENT B______________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER_____________
LAST FIRST M.I.
RELATIONSHIP TO APPLICANT ❑ FATHER ❑ MOTHER ❑ STEPFATHER ❑ STEPMOTHER
❑ GUARDIAN
ACTIVITY POSITIONS HELD/HONORS RECEIVED YEARS OF PARTICIPATION
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
❑ OTHER______________
________________________________________________________________________________________________________________________________
HOME ADDRESS (IF DIFFERENT FROM APPLICANT) CITY STATE ZIP
________________________________________________________________________________________________________________________________
HOME PHONE NUMBER CELL PHONE NUMBER EMAIL ADDRESS
________________________________________________________________________________________________________________________________
EMPLOYER OCCUPATION/TITLE WORK PHONE NUMBER
_________________________________________________________❑ MR. ❑ MRS. ❑ MS. ❑ DR. ❑ REV. ❑ OTHER ❑ Brebeuf Jesuit Grad (YEAR_______)
NAME OF STEPPARENT IN SAME HOUSEHOLD AS PARENT A (IF APPLICABLE)
________________________________________________________________________________________________________________________________
EMPLOYER/TITLE WORK PHONE CELL PHONE EMAIL
SIBLINGS
PLEASE LIST ANY COMMUNITY SERVICE AND/OR RELIGIOUS ACTIVITIES IN WHICH YOU HAVE BEEN INVOLVED IN. PLEASE NOTE
ANY LEADERSHIP POSITIONS AND/OR HONORS RECEIVED.
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
______________________________________________________________________________________
NAME CURRENT SCHOOL GRADE
❑ Brebeuf Jesuit Grad (YEAR_________)
Brebeuf Jesuit Tradition
Please list any other relatives who have graduated from Brebeuf Jesuit or any other Jesuit high school, college or university.
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
NAME RELATIONSHIP TO APPLICANT SCHOOL ATTENDED GRAD YEAR
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
PLEASE INDICATE THE CO-CURRICULAR ACTIVITIES IN WHICH YOU HAVE AN INTEREST IN PARTICIPATING DURING HIGH SCHOOL.
CO-CURRICULAR ACTIVITIES
❑ ACADEMIC SUPER BOWL
❑GLEE CLUB
❑ANIME CLUB
❑INDIANA UNIVERSITY HONORS PROGRAM
❑ART CLUB
❑IMPROV COMEDY CLUB
❑ASIAN CLUB
❑INTRAMURAL SPORTS
❑BLACK ROBE RUNNING CLUB
❑CELTIC CLUB
❑BLACK STUDENT UNION
❑JEWISH STUDENT UNION
❑BRAIN GAME
❑KENYA HELP US? CLUB
❑BREBEUF CLASSICAL CLUB
❑LEADERSHIP INITIATIVES
❑CHEM TEAM
❑LIFE CLUB
❑CHESS CLUB
❑MANITOU: LITERARY MAGAZINE
❑COEXIST CLUB
❑MATH COMPETITIONS
❑CONSERVATION CLUB
❑MODEL U.N.
❑DECA
❑NATIONAL HONOR SOCIETY
❑FEDERAL & ECON CHALLENGE
❑OUTDOOR CLUB
❑FRENCH CLUB
❑PACT (PEERS AGAINST CANCER TOGETHER)
❑RAK (RANDOM ACTS OF KINDNESS)
❑SCIENCE OLYMPIAD
❑SOFA (SERVICE ORIENTED FOOD APPRECIATION)
❑SPANISH CLUB
❑SPEECH & DEBATE
❑STRAP (STUDENTS TOGETHER AGAINST POVERTY)
❑STUDENT COUNCIL
❑SWEET HARMONY/MANIC BARCODE CHOIRS
❑THE JUSTICE LEAGUE (FORM. AMNESTY INT’L)
❑THEATRE
❑TIMMY FOUNDATION
❑YOUNG DEMOCRATS
❑YOUNG LIFE
❑YOUNG REPUBLICANS
IHSAA & CLUB SPORTS
BOYSGIRLS
❑BASEBALL
❑LACROSSE (CLUB)
❑BASKETBALL
❑BASKETBALL
❑SOCCER
❑BOWLING (CLUB)
❑BOWLING (CLUB)
❑SWIMMING
❑CHEERLEADING
❑CREW
❑TENNIS
❑CREW
❑CROSS COUNTRY
❑TRACK & FIELD
❑CROSS COUNTRY
❑FOOTBALL ❑VOLLEYBALL (CLUB)
❑CREW
❑GOLF
❑WRESTLING
❑DANCE
❑HOCKEY (CLUB) ❑DANCE
❑GOLF
❑LACROSSE (CLUB)
❑SOCCER
❑SOFTBALL
❑SWIMMING
❑TENNIS
❑TRACK & FIELD
❑VOLLEYBALL
BREBEUF JESUIT PREPARATORY SCHOOL STUDENT APPLICATION FORM
PAGE 4
STUDENTS AND PARENTS NEED TO PROVIDE RESPONSES TO THE FOLLOWING QUESTIONS.
THESE RESPONSES MUST BE TYPED ON A SEPARATE SHEET(S) OF PAPER. PLEASE SUBMIT YOUR
RESPONSES TO THE ADMISSIONS OFFICE ALONG WITH THIS APPLICATION.
APPLICANT/STUDENT ESSA<6
Brebeuf Jesuit Preparatory School
Application for Freshman Admission — CLASS OF 2017
Describe your interest in transferring to Brebeuf. Why would Brebeuf Jesuit be the best school for you?
☐ EARLY ADMISSIONS APPLICATION DEADLINE—October 15, 2012
☐ REGULAR ADMISSIONS APPLICATION DEADLINE—December 14, 2012
-
Explain how your academic achievements and experiences thus far have helped prepare you to succeed at Brebeuf Jesuit.
STUDENT INFORMATION
APPLICANT’S NAME ______________________________________________________________________________________________________________
LAST
FIRST
MIDDLE
GENDER ❑ FEMALE ❑ MALE PREFERRED FIRST NAME__________________________________________________________
MAILING ADDRESS________________________________________________________________________________________________________________
ADDRESS CITY STATE ZIP
PARENT’S LETTER OF RECOMMENDATION
HOME PHONE_____________________________________________ PLEASE WRITE A LETTER OF RECOMMENDATION TO THE ADMISSIONS COMMITTEE FOR YOUR SON OR DAUGHTER. THIS
RECOMMENDATION SHOULD INCLUDE A STATEMENT ON WHY YOU BELIEVE BREBEUF JESUIT AS A FAITH-BASED SCHOOL
AND YOUR STUDENT WOULD MAKE A GOOD MATCH, AND HOW YOU EXPECT YOUR SON OR DAUGHTER TO BENEFIT
FROM A BREBEUF JESUIT EDUCATION. PLEASE USE A SEPARATE SHEET OF PAPER
STUDENT CELL PHONE____________________________________________
STUDENT EMAIL______________________________________________________ DATE OF BIRTH____________________________________
U.S. CITIZEN? ❑ YES ❑ NO
(IF NO, ATTACH EXPLANATION OF STATUS)
RACE/ETHNICITY
❑AMERICAN INDIAN ❑ASIAN ❑BLACK / AFRICAN AMERICAN ❑CAUCASIAN / WHITE ❑ HISPANIC
❑PACIFIC ISLANDER ❑MULTIRACIAL, PLEASE SPECIFY______________________
❑ OTHER: PLEASE SPECIFY_________________________
RELIGION
❑ CATHOLIC ❑ HINDU ❑ JEWISH ❑ MUSLIM ❑OTHER:______________________________________________
EDUCATIONAL HISTORY
CURRENT GRADE_________
I HEREBY CERTIFY THAT THE INFORMATION ON THE APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. I FURTHER UNDERSTAND THAT IF ANY INFORMATION IS FALSIFIED IT MAY RESULT IN THE DENIAL OF
ADMISSION TO BREBEUF JESUIT.
________________________________________________________________________________________________________________________________
PRINTED NAME OF APPLICANT DATE
_______________________________________________________________________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN PRINTED NAME OF PARENT OR GUARDIAN DATE
________________________________________________________________________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN PRINTED NAME OF PARENT OR GUARDIAN ❑ NONE
PARISH OR PLACE OF WORSHIP________________________________________
NAME OF CURRENT SCHOOL______________________________________________________________
PREVIOUS SCHOOL (IF LESS THAN 2 YEARS IN CURRENT SCHOOL)____________________________________________________________________
APPLICANT/PARENT ACKNOWLEDGMENT & SIGNATURES
SIGNATURE OF APPLICANT ❑ PROTESTANT DATE
HAVE ANY SPECIAL CIRCUMSTANCES AFFECTED THE APPLICANT’S PERFORMANCE IN SCHOOL?
IF YES, PLEASE ATTACH AN EXPLANATION ON A SEPARATE SHEET.
❑ YES ❑ NO
HAS THE APPLICANT EVER BEEN SUSPENDED, EXPELLED, OR ASKED TO WITHDRAW FROM ANY SCHOOL? ❑ YES ❑ NO
IF YES, PLEASE ATTACH AN EXPLANATION ON A SEPARATE SHEET.
❑ APPLYING FOR THE LEARNING CENTER (SEE NOTE BELOW)
The Learning Center provides academic support services for students with a diagnosed learning difference. Applicants to the Learning Center must provide a
psychoeducational evaluation that has been completed within the last two years. All materials are kept confidential. Visit www.brebeuf.org/learningcenter for more
information.
MATH/SCIENCE TEACHER RECOMMENDATION
BREBEUF JESUIT PREPARATORY SCHOOL
VIA MAIL: BREBEUF JESUIT PREPARATORY SCHOOL
ADMISSIONS OFFICE
2801 W. 86TH ST.
INDIANAPOLIS, IN 46268
NAME OF APPLICANT ______________________________________________________________________________________________
Thank you for your time and care in completing this Teacher Recommendation for the above named student who is applying for admission to
Brebeuf Jesuit Preparatory School. We value your professional insight and candid appraisal of his/her academic performance, abilities and qualities
as a person. Given its confidential nature, please submit this form directly to Brebeuf Jesuit via mail to the address above. Please do not return
this form to the student or parents/guardians. Thank you for taking the time to complete this Recommendation Form.
How long have you known the applicant? __________________________________________________________________________________
Subject taught to the applicant? __________________________________________________________________________________________
GENERAL ACADEMIC ABILILTY
☐ SUPERIOR
☐ ABOVE AVERAGE
☐ AVERAGE ☐ BELOW AVERAGE
EXCELLENT ABOVE AVERAGE
AVERAGE
BELOW AVERAGE
SOCIAL RELATIONSHIPS WITH PEERS
☐ ☐ ☐ ☐
LEADERSHIP ABILITY☐ ☐ ☐ ☐
CREATIVITY☐ ☐ ☐ ☐
SELF-CONFIDENCE☐ ☐ ☐ ☐
SELF-CONTROL☐ ☐ ☐ ☐
RELATIONSHIPS WITH ADULTS
☐ ☐ ☐ ☐
CLASS PARTICIPATION☐ ☐ ☐ ☐
ABILITY TO FOCUS IN CLASSROOM
☐ ☐ ☐ ☐
Is the student habitually tardy or absent?
☐ YES
☐ NO
___________________________________________________________________________________________________________________
IF YES, PLEASE ELABORATE:
Has the student had any disciplinary issues? ☐ YES
☐ NO
___________________________________________________________________________________________________________________
IF YES, PLEASE EXPLAIN:
Please describe any special teaching or special accommodations/modifications that have been provided for the student:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
What are the first words that come to mind to describe this applicant?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
YOUR OVERALL RECOMMENDATION OF THIS APPLICANT FOR ADMISSION TO BREBEUF JESUIT:
☐ RECOMMEND ENTHUSIASTICALLY ☐ RECOMMEND ☐ RECOMMEND WITH RESERVATION ☐ DO NOT RECOMMEND
If this answer is “Recommend with Reservation” or “Do Not Recommend,” please explain:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
If you have additional information that will be helpful to the Admissions Committee in evaluating the student’s application, please comment.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
PRINTED NAME OF PERSON COMPLETING THIS FORM SIGNATURE DATE
___________________________________________________________________________________________________________________
SCHOOL
TELEPHONE
EMAIL ADDRESS
ENGLISH/SOCIAL STUDIES TEACHER RECOMMENDATION
BREBEUF JESUIT PREPARATORY SCHOOL
VIA MAIL: BREBEUF JESUIT PREPARATORY SCHOOL
ADMISSIONS OFFICE
2801 W. 86TH ST.
INDIANAPOLIS, IN 46268
NAME OF APPLICANT ______________________________________________________________________________________________
Thank you for your time and care in completing this Teacher Recommendation for the above named student who is applying for admission to
Brebeuf Jesuit Preparatory School. We value your professional insight and candid appraisal of his/her academic performance, abilities and qualities
as a person. Given its confidential nature, please submit this form directly to Brebeuf Jesuit via mail to the address above. Please do not return
this form to the student or parents/guardians. Thank you for taking the time to complete this Recommendation Form.
How long have you known the applicant? __________________________________________________________________________________
Subject taught to the applicant? __________________________________________________________________________________________
GENERAL ACADEMIC ABILILTY
☐ SUPERIOR
☐ ABOVE AVERAGE
EXCELLENT
☐
☐
☐
☐
☐
☐
☐
☐
SOCIAL RELATIONSHIPS WITH PEERS
LEADERSHIP ABILITY
CREATIVITY
SELF-CONFIDENCE
SELF-CONTROL
RELATIONSHIPS WITH ADULTS
CLASS PARTICIPATION
ABILITY TO FOCUS IN CLASSROOM
☐ YES
Is the student habitually tardy or absent?
☐ AVERAGE
ABOVE AVERAGE
☐
☐
☐
☐
☐
☐
☐
☐
☐ BELOW AVERAGE
AVERAGE
☐
☐
☐
☐
☐
☐
☐
☐
BELOW AVERAGE
☐
☐
☐
☐
☐
☐
☐
☐
☐ NO
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IF YES, PLEASE ELABORATE:
Has the student had any disciplinary issues?
☐ YES
☐ NO
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IF YES, PLEASE EXPLAIN:
Please describe any special teaching or special accommodations/modifications that have been provided for the student:
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What are the first words that come to mind to describe this applicant?
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YOUR OVERALL RECOMMENDATION OF THIS APPLICANT FOR ADMISSION TO BREBEUF JESUIT:
☐ RECOMMEND ENTHUSIASTICALLY ☐ RECOMMEND ☐ RECOMMEND WITH RESERVATION ☐ DO NOT RECOMMEND
If this answer is “Recommend with Reservation” or “Do Not Recommend,” please explain:
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If you have additional information that will be helpful to the Admissions Committee in evaluating the student’s application, please comment.
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PRINTED NAME OF PERSON COMPLETING THIS FORM
SIGNATURE
DATE
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SCHOOL
TELEPHONE
EMAIL ADDRESS