CLINICAL CARE EXTENDER PROGRAM
LETTER OF REFERENCE REQUEST FORM
All form fields are required. Form will not be processed if any fields are incomplete. NAME: E-MAIL:
(Permanent) ADDRESS: (Local) ADDRESS:
TODAY’S DATE: HOME PHONE: CELL PHONE: WORK PHONE: PAGER:
VOLUNTEER SITE:
Please check here if your contact information has changed since your entry into the program
PLEASE READ AND SIGN THE FOLLOWING STATEMENT: I have completed at least 200 floor hours (which excludes hours dedicated to meetings, trainings and Leadership Team office hours) and demonstrated commitment to the quality and standards of the program. I understand that my letter of reference will only be released to my designated institution(s) once I have completed 240 floor hours, the requirement for completion of my one year commitment to the Clinical Care Extender program. I am aware that my letter will not be written until all of the requested documentation has been submitted to the Clinical Care Extender Office. Further, I acknowledge the fact that the quality of my reference letter will reflect my overall performance within the program. SIGNATURE DATE CURRENT DEPARTMENT
PLEASE INDICATE THE PROGRAM TO WHICH YOU ARE APPLYING: MD RN PA DO MPH Other:
PLEASE INDICATE YOUR LETTER DEADLINE (MM/DD/YY):
PLEASE SUBMIT THE FOLLOWING DOCUMENTS WITH THIS COMPLETED FORM: Resume / curriculum vitae Personal statement Transcript (unofficial or official, if available) Brief description of what you did as a Clinical Care Extender and what you feel that you have gained from the program. Please include a list of all honors received including All Clinical Care Extender of the Rotation, Super Clinical Care Extender Award, staff recognition, etc. Signed waiver (optional) indicating that you have waived your rights to read your letter of recommendation (you can obtain this form from your current school or from the school to which you are applying.) Stamped and addressed envelope(s) Requests may take up to two months for completion of your letter. Letters written by the Manager, Director or CEO may take longer. Please request for your letter in advance to avoid delays in your application
------------------------------------------------------------ OFFICE USE ONLY --------------------------------------------------------------TOTAL HOURS: ____________________ FLOOR HOURS: ____________________ LETTER WRITTEN BY: _____________________________ 240 HOURS COMPLETED ON: __________________
DEPARTMENTS: ___________________________________________________________ VERIFIED BY: __________________________________
PRINT NAME
DATE: __________________ DATE LETTER SENT: __________________ DATE NOTIFIED: __________________
VERIFIED BY: __________________________________
SIGN NAME