Realityworks & Go Beyond
MCH Graduate Student Scholarship
2012
TO THE APPLICANT Please TYPE or PRINT
Full Name:
Address:
City, State, Zip Code:
Phone:
Email:
Fax:
The person completing the form, not the applicant, should return the reference form. The Realityworks & Go
Beyond MCH Graduate Student Scholarship Committee will use these comments for selection purposes only.
Permission: My typed name below indicates I hereby request that you complete and furnish this reference
information to The Realityworks & Go Beyond MCH Graduate Student Scholarship.
_______________________________________
Applicant’s Typed Signature
__________________________
Date
TO THE REFERENCE Please TYPE your responses
The person named above is an applicant for the Realityworks & Go Beyond MCH Graduate Student Scholarship.
The Selection Committee attaches considerable weight to the statements made by the references of the applicant.
The Committee is mindful of the time necessary to prepare this reference and gratefully acknowledges your help.
Please email the completed form by 8:00 pm Eastern Time on November 11, 2011 to the Realityworks & Go Beyond
MCH Graduate Student Scholarship at mchgradscholars@amchp.org. Please add the applicants name in the email
subject line.
Full Name of Reference:
Position/Title:
School/Firm/Organization:
Address:
City, State, Zip Code:
Phone:
Email:
Fax:
Please briefly answer the following questions:
1. For how long and in what capacity have you known the applicant?
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Realityworks & Go Beyond
2012
MCH Graduate Student Scholarship
2. What do you consider the applicant’s primary talents or strengths?
3. What is the applicant’s leadership style and in what activities have you seen them show their leadership style?
4. Please comment generally on the applicant’s interest in community affairs and potential for becoming an MCH leader.
UNABLE TO
JUDGE
POOR
AVERAGE
GOOD
EXCELLENT
Realityworks & Go Beyond
MCH Graduate Student
Scholarship SCALE
OUTSTANDING
Please rate the applicant on the qualities listed in the table below and using the listed scale of Outstanding, Excellent,
Good, Average, Poor, or Unable to Judge.
CHARACTER
ADVOCACY
INITIATIVE
INTEREST IN COMMUNITY AFFAIRS
LEADERSHIP
MATURITY
ORAL COMMUNICATION SKILLS
PERSISTENCE AND DRIVE
POISE
RESPONSIBILITY
My typed name below indicates that I support the application for this individual to this scholarship.
_______________________________________
Reference’s Typed Signature
__________________________
Date
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