Union College Health Professions Advisory Committee Individual Evaluation Letter Request Form

Instructions:

Complete one request form for each evaluator from whom you will be requesting a letter in support of your Health Professions Advisory Committee review.

Important information:

The evaluator will receive an email that includes your request for a letter in support of committee review and a link to the form and instructions.

Student Name*

First Name

Last Name

Student ID Number*

Student Class Year *

Student Union Email

Student Permanent Email *

Evaluator Name*

First Name

Last Name

Evaluator Email*

Select the program(s) to which you will apply. Please check all that apply.*

Allopathic Osteopathic Dental Pharmacy Physical Therapy Optometry

Other:

Waiver Form

Family Rights & Privacy Act

I hereby authorize the Health Professions Advisory Committee of Union College to prepare a letter of evaluation on my behalf and to submit said letter to the Admissions Offices of such health profession schools as I may designate to them in writing. I hereby waive all future access to this letter of evaluation under the provisions of the Family Educational Rights and Privacy Act of 1974: Public Law #93-380 (Buckley Amendment). In waiving future access I understand that I am waiving access to all faculty or other evaluations solicited in my behalf for the Committee for use in preparing the final composite letter of evaluation, as well as to the final letter itself. I understand that the Admissions offices of the professional schools will be cautioned about the confidential nature of these materials, and that they will be instructed not to use them for future purposes involving third parties. I further understand that if I do not waive future access to these evaluations, each correspondent, faculty or outside, must be so informed and may at his/her discretion choose not to allow use of any evaluation in my behalf. In addition, each school to which I apply must be informed that I have not waived future access to the final letter of evaluation. (Please review this document before making your selection. *Pros & Cons to waiving access to your file)

Please select one from below. NOTE: Your selection below must coincide with the waiver status indicated in your Health Professions Request for Committee Review form (see confirmation email).*

I do waive my rights to see my letter. I do not waive my rights to see my letter.

Date form completed*

Signature*

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