Nomination for After-School Boys Group

PLEASE RETURN NOMINATION FORMS TO MS. TSEGAYE OR MS. GAINES BY

December 14

We are going to start an after-school group for 4th and 5th grade boys! The group is meant for
students who may be struggling with multiple stressors and will focus on topics like Integrity,
Self-Control and Relationships.

Student: Section:

Reason for Nomination:

Areas of Concern:

Current Strengths and Interests:

Please rate the following

On Average, how frequently does the student display the following skills (RATE 0, 25, 50, 75,
100% of the time)
Communicates respectfully and clearly
0 25 50 75 100

Self-confidence
0 25 50 75 100

Integrity
0 25 50 75 100

Manages peer conflicts appropriately

0 25 50 75 100

Perseveres through difficult tasks

0 25 50 75 100

Displays Growth Mindset

0 25 50 75 100
 Nomination for After-School Boys Group

On average, how many days during the school week does the student display the following
behaviors (RATE 0, 1, 2, 3, 4, 5 days of the week)

Bullies peers or fights (verbal or physical)

1 2 3 4 5

Disrespectful to staff
1 2 3 4 5

Disruptive
1 2 3 4 5

Doesn’t complete work (including homework)

1 2 3 4 5