2023 年度
 1               慶應義塾女子高等学校
                 推薦入試                               入        学     志      願        書
                                                                                                              受験番号
 
 
 
 
 フリガナ
 
                                                                          生年月日           年          月         日
 氏     名                                                                                                                     写真貼付欄
                                                                                                                          縦 4 cm × 横 3 cm
                   〒（      ―               ）
                                                                                                                          写真裏面に氏名を
                                                                                                                          記入し，この枠内
 現住所                                                                                                                   に貼付すること。
 
                                                                        電話         ―           ―
 
 
        国公私立                                                       小学校   20    年    月 入学                   在籍期間        年    ヵ月
 学                                                                                                                 （備考）
        所在地
 
 
 
 
                                       都道                              市区                    卒業
 校                                                                                   年    月
                                       府県                              町村                      学年転出・修了
 歴     国公私立                                                        学校          年    月
                                                                                                 入学
                                                                                                                      在籍期間        年    ヵ月
                                                                                                   学年転入
                                                                                                                    （備考）
 （
 
        所在地
 
 
 
 
 上                                    都道                              市区                    卒業
 か                                                                                   年    月
 ら                                    府県                              町村                      学年転出・修了
 順                                                                                              入学
 に     国公私立                                                        学校          年    月                        在籍期間        年    ヵ月
 記                                                                                                学年転入
                                                                                                                    （備考）
        所在地
 
 
 
 
 入                                    都道                              市区                    卒業
                                                                                      年    月
 最                                    府県                              町村                      学年転出・修了
 終                                                                                              入学
 学     国公私立                                                        学校          年    月                        在籍期間        年    ヵ月
 校                                                                                                学年転入
                                                                                                                    （備考）
        所在地
 
 
 
 
 歴                                    都道                              市区                    卒業
 は                                                                                   年    月
 こ                                    府県                              町村                      学年転出・修了
 の                                                                                              入学
 下     国公私立                                                        学校          年    月                        在籍期間        年    ヵ月
 の                                                                                                学年転入
                                                                                                                    （備考）
        所在地
 
 
 
 
 欄                                    都道                              市区                    卒業
 に                                                                                   年    月
 別                                    府県                              町村                      学年転出・修了
 途                                                                                              入学
 記     国公私立                                                        学校          年    月                        在籍期間        年    ヵ月
 入                                                                                                学年転入
                                                                                                                    （備考）
        所在地
 ）
 
 
 
 
                                       都道                              市区                    卒業
                                                                                      年    月
                                       府県                              町村                      学年転出・修了
 最                                                                                              入学
                                                                                                                      在籍期間        年    ヵ月
        国公私立                                                         学校         年    月
 終                                                                                                学年転入         （備考）
 学
        所在地
 
 
 
 
 校                                    都道                              市区
                                                                                2 0 2 3 年 3 月 卒業見込
 歴                                    府県                              町村
 
 保護者氏名                                                                                            志願者との続柄：
 
                      〒（        ―               ）
 
 保護者現住所
                                                                                                  電話              ―           ―
 
 現住所以外の国内緊急連絡先（日中必ず連絡がとれる番号をご記入ください）
                                                                                             自宅・その他           会社名：
 氏名                              〔間柄：             〕 電話
                                                                                             携帯                   内 線：
 
                                                                                                                           裏面も記入すること
 
                                                                                                                                      ※   ※
 志願者氏名
 
 
 
  I．本校を志望した理由を詳しく書いてください。（志願者記入）
 
 
 
 
  II．本校に入学したらどのようなことをしようと思っていますか。（志願者記入）
 
 
 
 
  III．志願者を今までどのようにして育ててきましたか。 また，これからどのような人間になって欲し
       いとお考えですか。（保護者記入）
 
 
 
 
 記載者氏名                                            志願者との続柄：
 
 
                                                                                    ※   ※
      2023 年度                                                        ※
 
  2   慶應義塾女子高等学校
      推薦入試
                                                           受験番号
 
                                                         （※印欄には記入しないでください）
 
 
 
 
                             推         薦          書
 
                                             令和        年            月              日
 
 
 
 慶應義塾女子高等学校長 殿
 
 
 
 
                              学   校   名
 
 
 
 
                              校   長   名                                     校 長
                                                                               公 印
 
 
 
 
   下記生徒¹は，貴校にふさわしい生徒²であると認めますので
 推薦致します。
 
                                        記
 
 
 
      生 徒 氏 名
                                                                       2023 年度                                                                                                                     ※
 
      3                                                                慶應義塾女子高等学校                入学志願者調査書                                                       受験番号
                                                                       推薦入試
                                                                                                                                                                                （※印欄には記入しないでください）
  黒または青のインク（ボールペン使用可）でご記入ください
      学 籍 の 記 録
 
 
                                       フリガナ                                                                                                                  生年月日                      年         月            日生
 
                                       氏                              名                                                                                        入      学     2 0            年         月    入           学
 
                                                                              国            立                                                                   転 入 学       2 0            年         月    編・転入学
                                       学校名                                 公            立                                   中学校
                                                                              私            立                                                                   卒      業     2 0 2 3        年    3    月    卒業見込
 
                                                                                       学 年          年        年          年                                           学 年            年              年            年
                                       教 科                                                      1        2         3                                        項 目                   1              2              3
 
 
 
 
                                                                                                                                       出 欠 の 記 録
      各
 
                                        必
 
 
 
 
                                                                        国              語                                                                     授 業 日 数¹
                                                                        社              会                                                                     1. 欠 席 日 数²
      教
 
                                        修〈 五段階評価による評定 〉
 
 
 
 
                                                                        数³              学                                                                     2. 遅 刻 回 数⁴
      科
 
 
 
 
                                                                        理              科                                                                     3. 早 退 回 数⁵
                                                                        音              楽
      の
 
 
 
 
                                                                                                                                                               1.2.3.の合計
                                                                        美              術                                                                            3 年次は12月末までの数⁶値を記入
      学
 
 
 
 
                                                                        保健体育
                                                                        技術・家庭
      習
 
 
 
 
                                                                                                                                       特 別 活 動 の 記 録
 
 
                                                                        外    国       語                                                                      1年
      の
 
 
 
 
                                                                        評定合計
                                        選
      記
 
 
 
 
                                                                                                                                                               2年
      録
 
                                        択
 
 
 
 
                                                                                                                                                               3年
                                                                                       学 年          年        年          年
                                       項 目                                                      1        2         3
      行動の記録（満足できる ↓ 印）
 
 
 
 
                                       基本的な生活習慣
                                       健康・体力の向上                                                                                                       学校生活全般について，記載責任者の所見をご記入ください
                                                                                                                                       総
 
 
 
 
                                       自                               主・自           律
                                       責                                    任          感
                                                                                                                                       合
 
 
 
 
                                       創                               意        工     夫
                                       思 い や り・ 協 力
                                                                                                                                       所
 
 
 
 
                                       生命尊重・自然愛護
                                       勤                               労・奉           仕
                                                                                                                                       見
 
 
 
 
                                       公                               正・公           平
                                       公共心・公徳心
 
 
 上記の記載事項に誤りの無いことを証明する
 
 令和                                                             年          月          日
 
 学校所在地                                                                  〒（                −        ）
 
 学                               校                              名                                                              電                             話              −                 −
                                                                                                                     校長
 校                               長                              名                                                 公印         記載責任者                                                                            
 
                                                                                                                                                                                                               ※       ※
       2023 年度                                                                                      ※
                                                                                       受験番号
 4     慶應義塾女子高等学校
       推薦入試                                                                   （※印欄には記入しないでください）
 
 
 
 
         「学習成績一覧表」の評定人数⁷分布票
 
                                                           令和                   年            月         日
 
 
     2022年度 第 3 学年の評定
 
 
                                              学 校 名
 
                                                                                                            校長
                                              校 長 名                                                      公印
 
 
 
 
   ［ 第 3 学年の成績分布 ］
                                                                                            （公印以外はコピー可）
                        国
 
 
                               社
 
 
                                      数⁸
 
 
                                              理
 
 
                                                     音
 
 
                                                             美
 
 
                                                                    保 健 体 育
 
 
                                                                                         技術
 
 
                                                                                                     外
         教     科
                                                                                                     国
                                                                                                           備      考
                                                                                       家
                                                                                       ・ 庭
                        語
 
 
                               会
 
 
                                      学
 
 
                                              科
 
 
                                                     楽
 
 
                                                             術
 
 
 
 
                                                                                                     語
 
 
 
  段     階
 
 
  5 を与えた人数⁹
 
  4 を与えた人数¹⁰
 
  3 を与えた人数
 
  2 を与えた人数
 
  1 を与えた人数
 
     合 計 人 数
 
 ※分布票を作成していない場合は，欄外にその旨を記載し，公印を押してください。
             2023 年度
                                      活 動 報 告 書
                                                                                   ※
 
   5         慶應義塾女子高等学校
             推薦入試
                                                                       受験番号
 
                                                                     （※印欄には記入しないでください）
 
   フリガナ
 
  志願者氏名
 
 
 
 
 上記の記載事項に誤りのないことを証明する
 
 
 令和     年       月   日
 
 
   学   校    名                                   電      話   ―         ―
 
                                            校長
   校   長    名                            公印   記載責任者                                  
 
 
 
 
                                                                                          ※    ※
           2023 年度
   6       慶應義塾女子高等学校      資料貼付用紙                             受験番号
           推薦入試
 
 
 
                                  都道                    市区
  志願者    所在地                                                フリガナ
                                  府県                    町村
  出 身
  中学校    国   公   私   立                         中学校     志願者氏名
 
 
 「中学生として諸活動に積極的に取り組んだ」ということを証明する賞状・新聞記事・資格認定書など
 のコピー（縮小可）を貼付すること。これらがない場合は，「貼付資料なし」に ○ をつけて提出すること。
 貼付資料が多い場合は，この用紙の裏面に貼付すること。
 
 
 
 
                                           貼付資料なし
 
 
 
 
                                                                                         ※   ※
           2023 年度
  7        慶應義塾女子高等学校
           推薦入試
                                                                          受験番号
 
 
 
 
                                     健       康   調     査      書
 
 フ リ ガ ナ
                                                                  生 年
                                                                  月 日              年   月   日生
 氏        名                                                     （西暦）
 
                 〒（          ―        ）
 
 現 住 所
 
 
 
 
  入学試験において，既往症を含め健康管理上特に本校が配慮を要する事項
 
      な    し
 
      あ    り       具体的に：
 
 
 
 
  令和          年        月        日
 
 
 
 
                          記載保護者氏名                                                  
 
 
 
 
 （注） この健康調査書は，志願者の保護者が記載してください。
         なお，本調査書の内容は，入学試験の合否には一切関係ありません。