Principal/College Advisor Reference Form

[Pages:4]Principal or College Advisor Reference Form

TO THE APPLICANT: Please fill in the information below and give this form to your principal or college advisor (counselor). NAME OF APPLICANT: ____________________________________________________________ WCM-Q APPLICANT ID #: _____________ TELEPHONE (with country code): ___________________________ E-MAIL ADDRESS: _______________________________________ Applicants who are admitted and enroll at Weill Cornell Medicine-Qatar (WCM-Q) have the right, under the Family Educational Rights and Privacy Act of 1974 (FERPA), to see written evaluations submitted on their behalf, unless they have waived that right. Please indicate your choice below by checking the corresponding box and signing below. Your choice will not be a factor in considering your application. Please check one of the options below:

_____ I waive my right to see this letter.

_____ I do not waive my right to see this letter.

APPLICANT'S SIGNATURE: __________________________________ DATE: _________________ ____________________________________________________________________________________________ TO THE PRINCIPAL/COLLEGE ADVISOR: Please fill out all of the sections and return the entire Principal/College Advisor Form to the address indicated on the last page. We appreciate your time and effort in filling out this evaluation, as your reference is critical in our assessment of the suitability of this applicant for admission to our program. NAME: ______________________________________________________________________________ TITLE: ____________________________________________ TELEPHONE (with country code): _______________________ E-MAIL ADDRESS: ___________________________________

SELECT YOUR ROLE: _____Principal _____College Advisor/Counselor

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NAME OF APPLICANT: _______________________ WCM-Q ID #: ______________________________

SCHOOL NAME: _______________________________________________________________________

ADDRESS OF SCHOOL

STREET: _______________________________________

CITY: ____________________

STATE: _____________ POSTAL CODE: __________ COUNTRY: _____________________

How long have you known the applicant? _________________________________________________________________________

GRADE POINT AVERAGE

1. The applicant's overall Grade Point Average (GPA) is __________________________

2. The applicant's GPA is based on a point scale of ______________________________

3. This applicant's GPA is (Select One) _____ Weighted

_____ Not Weighted

CLASS RANK (Comparative Performance within a graduating class, as measured by overall Grade Point Average)

1. The number of students in the graduating class is ______________________________

2. This applicant's rank is (Select One) _____ Weighted

_____ Not Weighted

3. This student's rank number is _________________

4. How many graduating seniors have higher rank than this applicant? ________________

5. If a precise rank is not available, please indicate the approximate ranking of this student (i.e. top 10th, 20th, 30th, etc.) ___________________________________________________

6. What percent of students continued on to university from the previous class? ________

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NAME OF APPLICANT: _______________________ WCM-Q ID #: ______________________________

RATING Compared to all of the other university-bound students you have known, how do you rate this applicant in terms of the following?

General Ratings

Academic Potential

Top 5%

Top 15%

Top 25%

Upper Half

Lower Half

No Basis For Rating

Character and Personal Potential

SCHOOL INFORMATION

1. Please rate the overall rigor of the academic program undertaken by this student, compared with that of his or her university-bound classmates (Select One)

STANDARD

ADVANCED

MOST RIGOROUS

2. Does your school offer its students AP, A-Level, or IB courses? (Select One)

YES

NO

3. If YES for Question 2 above, how many courses? (Select One)

1 - 3

4 - 5

6 - 10

11 OR MORE

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NAME OF APPLICANT: _______________________ WCM-Q ID #: ______________________________ Please write a summary report and recommendation in support of this student's application to the SixYear Medical Program at Weill Cornell Medicine-Qatar (WCM-Q). You may attach a separate letter with this reference and indicate that accordingly in the space below. Please appraise the applicant's academic and personal qualities. Discuss the applicant's special talents and characteristics, commitment to academic work, non-academic achievement, and specific events or unusual circumstances that may have affected the applicant's performance in secondary school. Please provide us with any information you feel is useful in helping us assess this applicant's ability to succeed in our program.

SIGNATURE OF REFERENCE: _______________________________ DATE: __________________ PLEASE SEND THE ENTIRE PRINCIPAL/COLLEGE ADVISOR REFERENCE FORM IN A SCHOOL SEALED ENVELOPE DIRECTLY TO: OFFICE OF ADMISSIONS WEILL CORNELL MEDICINE-QATAR AL-LUQTA STREET, P.O. BOX 24811, QATAR FOUNDATION ? EDUCATION CITY DOHA, QATAR TELEPHONE: +974-4492-8500 E-MAIL: ADMISSIONS@QATAR-MED.CORNELL.EDU

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