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* 1. Student Name

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* 2. School Name

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* 3. Your Name

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* 4. Your Role in the Student's Life

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* 5. How long have you know the student?

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* 7. Describe the student's strengths based on the above answer

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* 8. Describe how you believe this program will strengthen the student.

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* 9. What outside supports do you believe the student has to assist them in being successful in this program?

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* 10. If we need to contact you for further information please submit your email address and phone number

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