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

First Name

Last Name

Email Address

Phone

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

Current or Past Employer/Coworker
Current or Past Teacher/Instructor
Coach
Volunteer Program Supervisor
Clergy/Minister
Other
Other

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.

Signed

Date

Scholarship Reference Form

Scholarship Reference Form

REFERENCES MUST BE SUBMITTED ON OR BEFORE MARCH 31, 2017