HPAC Student Form 1
Request to Prepare a Committee Letter of Recommendation (Form 1)
Please answer question Student name before continuing.
I request the Health Professions Advisory Committee (HPAC) to prepare a committee letter of reference for me. The purpose of the reference is admission to an educational institution in the health professions (indicate specific type of institution below). The committee will release this prepared letter to specific educational institutions upon my request utilizing Form 2: Authorization to Send Committee Letter of Recommendation.
I authorize the HPAC to release information and provide an evaluation about any and all information from my education records at Grinnell College, including information pertaining to my education at other institutions I have previously attended which is a part of my education records at Grinnell College. The HPAC is authorized to solicit opinions from each of the instructors of record for courses on my transcript as well as the individuals at Grinnell College indicated below. I further authorize the HPAC to seek confidential information from the Vice President for Student Affairs concerning any conduct or academic honesty offenses at Grinnell College, the severity of the offense, and any penalties imposed.
I understand further that: (1) I have the right not to consent to the release of my education records at Grinnell College; (2) except as may be provided by my waiver indicated below, I have a right to receive a copy of any written reference upon request; and (3) that this consent shall remain in effect until revoked by me, in writing, and delivered to the HPAC, but that any such revocation shall not affect disclosures made prior to HPAC's receipt of my written revocation.
Contact Michelle Sears at (641) 269-3172 or by email at firstname.lastname@example.org if you have any questions.
Please answer question (medicine, nursing, veterinary, med. technician, etc.) before continuing.
I am applying to the following type of graduate health professions educational institution
(medicine, nursing, veterinary, med. technician, etc.)
Please answer question Grinnell Major before continuing.
Please answer question Tutorial Advisor before continuing.
Please answer question Major Advisor before continuing.
Please answer question Graduation Year before continuing.
Provide the following information
Student ID Number
Please answer question residence before continuing.
State of legal residence
(Click here to choose)
Not a US resident
DISTRICT OF COLUMBIA
Please answer question Previous application before continuing.
Have you filled out a Form 1 before?
Yes. If yes, when?
Please answer question Likelihood before continuing.
Rate the likelihood that you will apply in the next 6-8 months, with 10 being certain that you will apply.
Please answer question Waiver before continuing.
By completing and submitting the required information on this electronic form:
I hereby waive all rights of access which I may have, now or at any time in the future, to any reference provided in response to this request.
Please answer question E-mail before continuing.
Your answer to question E-mail must be a valid email address.
Current Contact Information
The following names and email addresses are of individuals at Grinnell College that I ask HPAC to query in addition to my professors of record (e.g. coaches, work supervisors, etc.). I also list particular professor(s) with which I have developed a close relationship that could speak well on my behalf. Include their name, email address, and your relationship.
Extracurricular activities and experience are
to most professional schools. Give here the extracurricular activities in which you
participated and any experience you have had in employment during the summers and vacations, especially if related to any of the health professions. Please be as specific as possible.
Submit a 100-200 word essay describing why you wish to enter the profession to which you are applying and what prompted your decision. This section is also very important. We recommend that you exercise due diligence in its preparation. A well-written essay will help the Health Professions Advisory Committee to prepare the strongest possible letter of recommendation.
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