Health Professions Advisory Committee Letter of Evaluation

Health Professions Advisory Committee Letter of Evaluation
Request, Waiver, and Inspection Form

Date of Request:	05/17/2012
Student's Name:
Class of:
Student's Academic Major(s):
Stevenson University Student ID Number:
Applying to which type of health professions program:

To the Student:
Please provide the information requested in numbers 1-5 above. Then, read your rights provided by the Family Rights and Privacy Act of 1974. The student must initial one of the following statements and sign this form before submitting it to the HPAC. This request is in compliance with Federal Law P.L. 93-380 (Family Educational Rights and Privacy Act of 1974).

I have read the summary of the Family Education Rights and Privacy Act on the Stevenson University website. I understand that federal legislation provides me with a right of access to confidential letters of evaluation relating to applications for admission to another school, for a job, or for an award, and that no school or person can require me to waive this right.

In connection with my application to medical, dental, or other health professions schools. . .

WAIVER

I hereby voluntarily waive and relinquish any right of access to this confidential letter of evaluation.

I retain my right of access to this letter of evaluation.

INSPECTION

I grant permission to the HPAC to review my official student records as kept by the Registrar & the Deans of the University.

I deny permission to the HPAC to review my official student records as kept by the Registrar & the Deans of the University.

I give permission to the Health Professions Advisory Committee (HPAC) to write a composite letter of evaluation and to send it to the medical, dental, or other health sciences schools to which I am applying for admission. It is my understanding that the evaluation will be based upon the HPAC's knowledge of my academic performance and character traits, as well as the letters received by them on my behalf. The HPAC has my permission to include my grades, grade point average, class rank, and any information I have provided in my autobiographical sketch, and to use gender-specific pronouns in this letter.

Signature:
Date:	05/17/2012

Submission of online health professions documents will include the use of an electronic signature which is accepted as the equivalent of a handwritten signature.