School of Nursing (724) 656-4052

JAMESON MEMORIAL HOSPITAL SCHOOL OF NURSING

REFERENCE FORM

            (This reference form is to be submitted with the application)

References should be from teachers, employers, clergy, or counselors with whom the applicant has had professional relationships.  References from family members or friends are NOT accepted. Submitting inappropriate references will delay the admission process.

Name of Applicant ___________________________________

To assure that your records are held in compliance with the law as stated below, please check one:

                                _____ I GIVE UP my right to read this reference form.

                                _____ I DO NOT GIVE UP my right to read this reference form.

Applicant Signature______________________________________    Date _________

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The above named applicant is a candidate for admission to the School of Nursing and has named you as a reference person.  Your comments will be used only by the Faculty members of the school to assist them to arrive at a better understanding of this applicant.  Your cooperation in completing this form will assist both the applicant and the School of Nursing.

                Please Note:  Public Law No. 93f-380 grants a student access to his/her records as maintained by the School of
                     Nursing.  It also grants a student or an applicant the right to waive access.  See above for the student’s choice
                     regarding confidentiality. 

I have known the applicant in the following capacity: __________________________________________________

I have known the applicant for _________ months  _________ years.

I would evaluate the applicant as follows: 

RECOMMENDATION: 

`                                               _____ Strongly Recommend                                           _____ Recommend with Reservation

                                                _____ Recommend                                                          _____ Not Recommend

Comment (s): 

Signature _______________________________________  Date __________  Position ________________________

Address   _______________________________________________________________________________________

Telephone ______________________

 Please return this form with the application  or mail to:   

          Jameson Memorial Hospital School of Nursing
                          1211 Wilmington Avenue
                          New Castle, PA  16105 - 2595