Scholarship Reference Form

Scholarship Reference Form

Scholarship Applicant's Name

The above student is applying for a health profession scholarship through The Christie Foundation and is requesting that you provide a reference for them. Please complete the form below on or before March 31, 2017. All information included in this reference will be considered confidential. If you have any questions or need any assistance with completing this form, please contact Laura Mann, lmann@christieclinic.com or (217)366-1271.

Contact Information








What is your relationship to the applicant? (no family members please)








Please rate the applicant in the following categories
Compassion
Communication skills
Dependability
Extracurricular/community involvement
Initiative
Judgment
Leadership
Reaction to setbacks
Intellectual curiosity
Overall recommendation
Additional Comments: (Strengths, weaknesses, or any other relevant information)

I certify that the above is an accurate and impartial recommendation and that I have no familial ties to the applicant. I understand that typing my name below will be considered my electronic signature.





REFERENCES MUST BE SUBMITTED ON OR BEFORE MARCH 31, 2017