2021 MedQ Exlore Reference Form

The student is applying for the MedQ Explore program which will be held on an online platform this summer. Your candid assessment is important for this student’s competitive application. We need your feedback regarding this student’s ability to learn and participate in a structured online group setting, and to contribute in a respectful manner. Please note: One non-family reference is required for each student. The student’s application to MedQ Explore will not be considered unless this completed reference form is submitted our office by the deadline of midnight on March 8, 2021.

Student's Name:

First Name Last Name

High School:

Your Name:

First Name Last Name

Your relationship with student:

Student's strengths as you see them:

Student's challenges as you see them:

Please rate the student in the following areas and provide comments:

RATING SCALE: 1 = poor, 5 = excellent

Social Skills

Respect for teachers or adults

1 2 3 4 5

Appropriate interaction with peers

1 2 3 4 5

Interacts with many groups of people

1 2 3 4 5

Adapts to new settings easily

1 2 3 4 5

Communicates clearly and effectively

1 2 3 4 5

Please comment on your overall impression of the student’s social skills:

Motivation

Gets excited about learning new things

1 2 3 4 5

Sets challenging goals for himself/herself

1 2 3 4 5

Works hard to achieve his/her full potential

1 2 3 4 5

Please comment on your overall impression of the student’s level of motivation:

Personality & Skills

Leadership ability

1 2 3 4 5

Identifies and makes good choices

1 2 3 4 5

Ability to sit through presentations that may not be of interest

1 2 3 4 5

Maintains a positive attitude

1 2 3 4 5

Is a responsible, considerate, mature adolescent

1 2 3 4 5

Will interact professionally with presenters, professionals, and other students

1 2 3 4 5

Please comment on your impression of the student’s personality, maturity and skills:

Academic Ability/Interests

Strong interest in healthcare careers

1 2 3 4 5

Interest in career education

1 2 3 4 5

Turns in work on time (if applicable)

1 2 3 4 5

Takes assignments seriously and does a thorough job

1 2 3 4 5

Asks questions/is eager to learn

1 2 3 4 5

Please comment on your impression of the student’s academic ability and interests:

Check any that apply:

Student is struggling with some difficulties in life right now Student has struggled but has been working hard to make improvements Student requires frequent behavioral redirection Student is shy but is able to act in a professional manner

Additional Comments:

Thank you for supporting this student's career exploration efforts! Please contact Eleanor Thomas, MedQ Explore Director, at the contact information below if you have questions or additional feedback.

Email: ethomas@svtahec.org, Phone: 802-885-2126 x 103

2021 MedQ Explore Reference Form