Appendix F
Information Sheet for Health Professions Committee
(Return to Karen Renneke – Chemistry RHS 336)
Today’s Date ______________
Applicant __________________________________ S.S.# ____________________ Graduation Year _____________
Please print
Hometown/Primary Residence______________________________State__________________
Email Address___________________________________________Phone_________________
I request and authorize the Health Professions Committee to prepare a committee Letter of Evaluation for me for submission to professional schools to which I apply. I understand that the Health Professions Committee has access to my transcript, my test scores, and that it may request a report on disciplinary action from the Associate Dean of Students. This statement is provided in accordance with The Family Educational Rights and Privacy Act of 1974.
I (check one)_____waive _____ do not waive my right of access to the Health Professions evaluation letter and the dossier prepared on my behalf.
Applicant Signature______________________________________ Date __________________
1. Major(s)_________________________________ Concentration(s) ____________________
2. Future career plans
a. Short-range goals
b. Long-range goals
3. Motivation for career in __________ (may add an extra page)
4. Experiences
a. Employment (since high school)
- On campus
- Summer
b. Experience related to health professions (i.e., volunteer, internships, informal observations)
c. Research experience (when, where, topic)
d. Leadership experience (when, where)
5. Extracurricular activities (music, athletics, service organizations, religious life, etc.)
6. Hobbies and special skills (computer, photography, etc.)
7. St. Olaf faculty to complete the evaluation form (3-5 names). It is your responsibility to see to it they receive the
form and complete it. Form must be received by April 1st to ensure an Interview in the spring.
a. ______________________________________
b. ______________________________________
d. ______________________________________
e._______________________________________
c. ______________________________________
8. Anything else the committee should know.
9. Do you intend to apply for early decision? _________________________________________________
Please attach a current unofficial grade audit to this form.
Interviews will be scheduled after the information sheet, an audit, and at least three faculty evaluations have been received.
