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Health Professions Advising - Evaluation and Committee Letter Request
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NOTE:
After you complete this form and submit it -
DO NOT
make changes/updates/corrections to this form and resubmit yourself without contacting Jane Byrnes first. Thank you!
HIDDEN: Current CC Program
ECE 101
Pre-Health
Social Action Institute
Student Information
First Name *
Preferred Name
Middle Name
Last Name *
Birthdate *
Birthdate *
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Email *
Additional email address to send confirmation (optional)
CCID *
Evaluation Information
What type of school are you requesting evaluations for? *
Medical
Dental
Veterinary
List the names of three to five Colorado College faculty or staff members and individuals outside the college community (supervisor, medical professional) who have insight about you. Select evaluators from a variety of disciplines (mix it up a bit) who you feel will describe your strengths and be a strong advocate.
If you have worked in a hospital, in a research lab, or for a doctor, letters from your supervisor or doctor are a valuable addition to your admission packet. Give each evaluator your resume and your personal statement.
How many evaluators are you requesting to write a letter on your behalf? *
1
2
3
4
5
6
Evaluator One - First Name *
Evaluator One - Last Name *
Evaluator One - Email *
Evaluator One - Relationship (How do you know this person?) *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Evaluator Two - First Name *
Evaluator Two - Last Name *
Evaluator Two - Email *
Evaluator Two - Relationship *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Evaluator Three - First Name *
Evaluator Three - Last Name *
Evaluator Three - Email *
Evaluator Three - Relationship *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Evaluator Four - First Name *
Evaluator Four - Last Name *
Evaluator Four - Email *
Evaluator Four - Relationship *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Evaluator Five - First Name *
Evaluator Five - Last Name *
Evaluator Five - Email *
Evaluator Five - Relationship *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Evaluator Six - First Name *
Evaluator Six - Last Name *
Evaluator Six - Email *
Evaluator Six - Relationship *
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted as confidential to the Health Professions Advising Committee of Colorado College, and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the above letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Committee Letter Waiver
In order to maintain the confidentiality and integrity of the evaluation process, it is important that the individuals you select as evaluators are aware of whether of not you waive access to the evaluation letters. Complete the provided Letter of Evaluation Request and Waiver for your specific field/discipline and present it to each evaluator. For the above mentioned reasons, we also require that you indicate whether or not you waive your access to the Health Professions Advising committee letter.
The committee letter will not be written until you have electronically signed this waiver and all required personal information forms to the HPA Office. *
Note: As the letters from your evaluators are often included in the HPA committee letter, be advised that access waived to any portion of the letter automatically waives access to the entire HPA committee letter.
I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the committee letter of evaluation submitted by the Health Professions Advising Committee of Colorado College and I certify this waiver is given voluntarily.
I hereby DO NOT waive my rights under the Family Educational Rights and Privacy Act of 1974, as amended, to examine the committee letter of evaluation submitted by the Health Professions Advising Committee of Colorado College.
Electronic Signature (Please type your full name) *
Submit
