Reference Form

EVALUATOR INFORMATION
An application for admission to CIP requires evaluations from two people capable of judging the career and academic promise of the applicant. Please submit this form as soon as possible.
APPLICANT INFORMATION
Applicant Name*
First Middle Last
EVALUATOR'S INFORMATION
Your Name*
Prefix First Middle Last Suffix
Your Email*
Your Phone*
Your Title*
Organization
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
IN WHAT CAPACITY DO YOU KNOW THE APPLICANT?*
HOW LONG HAVE YOU KNOWN THE APPLICANT?*
HOW DOES THIS APPLICANT COMPARE WITH THEIR PEER GROUP IN ABILITY?*
PERSONAL EVALUATION OF THIS APPLICANT
What particularly qualifies this student for study at CIP? Information about accomplishments will be particularly helpful. If you have any reason to believe that the applicant should not be considered, please explain.*
Please feel free to add information about your own educational and professional background if you feel that such information will enhance our understanding of your evaluation.
PERSONAL CHARACTERISTICS OF THE APPLICANT
I am comparing this student to peers of similar age that are:
- On the Autism Spectrum/Learning Difference/Special Education
- Neurotypical Students
- Other (please specify below)
If other, please specify:
RATE THE CHARACTERISTICS LISTED BELOW
Adaptability
Concern for others
Emotional maturity
Leadership potential
Personal initiative
Respect accorded to faculty
Respect accorded to peers
Self confidence
Sense of humor
Creativity
Regulates gaming/computer use
Maintaining relationship with peers
Ability to manage stressful situations
Ability to manage emotions in times of frustration
ACKNOWLEGEMENT
I AFFIRM THE ACCURACY OF ALL STATEMENTS ON THIS FORM.*
- I Agree
Optional: Join the CIP email list
- Join
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Owner ID
For internal use - all contacts must have an owner and the default owner is Frankie.

Reference Form

EVALUATOR INFORMATION

APPLICANT INFORMATION

EVALUATOR'S INFORMATION

PERSONAL EVALUATION OF THIS APPLICANT

PERSONAL CHARACTERISTICS OF THE APPLICANT

RATE THE CHARACTERISTICS LISTED BELOW

ACKNOWLEGEMENT