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, 2018. 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 Please rate the applicant in the following categories Compassion Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Communication skills Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Dependability Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Extracurricular/community involvement Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Initiative Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Judgment Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Leadership Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Reaction to setbacks Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Intellectual curiosity Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate Overall recommendation Superior (Top 1%) Excellent (Top 10%) Above Average Average Below Average Unable to Rate 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 REFERENCES MUST BE SUBMITTED ON OR BEFORE MARCH 31, 2018