LSC-O Emergency Medical Services

Emergency Medical Services Reference Request

Date _______________

____________________________________________ is requesting that you provide a letter of reference regarding their admission to the Emergency Medical Services Program. After completing this form, please return it to the address shown at the end. Thank you for your valuable contribution.

I have known the applicant for ______ years, ______ months.

The circumstances under which I have known the applicant are:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

On the following chart, place a check in the box that matches the rating you would give the applicant.

Personal Attributes Exceptional Above Average Average Below Average No Information
Intellectual Capacity          
Writing Ability          
Oral Communication Skills          
Problem-Solving Skills          
Intellectual Curiosity          
Motivation to Learn          
Perseverance in Adversity          
Likelihood of Success in the EMS health care field          
Ability to Get Along with Others          
Dependability, Attendance          

Please include any comments that would assist faculty members in the decision of admitting the applicant to the Emergency Medical Services Program. (If more space is needed, attach an additional sheet.)

________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

Please send form to:
Standards Committee
Emergency Medical Services Program
Lamar State College-Orange
410 Front Street
Orange, Texas 77630


Signature ___________________________________________________________________________

Name (printed or typed) ________________________________________________________________

Position/Title ________________________________________________________________________

Address ____________________________________________________________________________