2014 SUMMER RADIOLOGY CAMP REFERENCE RELEASE FORM I have submitted your name to Bellin College as a reference for their Summer Radiology Camp. My signature gives you permission to release information about me regarding my suitability for a career in radiology. Please complete the reference form below and mail or fax to:
Bellin College – Summer Radiology Camp 3201 Eaton Road Green Bay, WI 54311 Fax: (920) 433-1922
Academic Reference (check one): Math Teacher Science Teacher Counselor Health Teacher Principal How long have you known the applicant? ________ Name: ______________________________________ Institution: __________________________________ Phone Number: ______________________________ Email: _____________________________________
Please return by April 30, 2014 Please PRINT or TYPE all information on this form Name of Applicant: ________________________________________________________________________________ Last Name ___________________ Date
First Name ____________________ Phone Number
Middle Initial _________________________________________ Applicant’s Signature
Applicant: Be sure to indicate if this reference is a teacher, counselor, or principal at the top portion of this form. Please date and sign this form before sending this to your reference. Reference: The above applicant has applied to attend our Summer Radiology Camp. The purpose of this camp is to educate students about the possibilities of radiology as a profession. 1.
What specific qualities does the applicant have to succeed in a career in radiology? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
2.
What impresses you most about the applicant? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
3.
Teacher/Counselor/Principal recommendation: Please indicate whether you recommend the applicant as someone who demonstrates characteristics suitable for a career in radiology (academic ability, integrity, and maturity). Recommend Highly Recommend Hesitate to Recommend Do Not Recommend Comments:
______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
