Request for Faculty Recommendations

Marywood University
APPLICATION FOR ADMISSION
TO
THE COORDINATED PROGRAM IN DIETETICS
Please complete this form, typed [use Tab key to move from line to line] and return it with your other application materials to:
Director of CP, Department of Nutrition & Dietetics, Marywood University, 2300 Adams Avenue, Scranton, PA 18509
A. PERSONAL DATA: Application is hereby made for admission of:
Name:
First / Initial / Last
Local address:
Address:
City / State / Zip code
Local Telephone #: / Cell number
Date of Birth / Present Age
Home Address (If different than above)
Address:
City / State / Zip code
Home Telephone #
Email address:
WORK/SERVICE EXPERIENCES: List any paid and/or volunteer work experiences, beginning with your present or most recent experience.
Dates
From - To / Paid or
Volunteer / Place & Address / Hours per
Week / Description of Work / Supervisor & title
LEADERSHIP POSITIONS: List college and community leadership positions beginning with the most recent (i.e., board position in SDA, team captain, etc.).
Dates
From – To / Position / Organization
HONORS AWARDED: List college academic or leadership awards received (i.e., trophies, honors certificates, medals, merit scholarships, commendations, etc.).
Date of Award / Type of Award / Activity which Prompted Award
PRESENTATIONS: List outside presentations related to Nutrition and Dietetics that you presented, not including those required for a class.
Date / Title of Presentations / Length of Presentations
TRANSCRIPTS: List all colleges/universities you are sending official transcripts from.
Name of College/University
I certify that the above information is true to the best of my knowledge. I agree that if I am accepted for admission, I shall comply with all the rules and regulations of the Coordinated Program in Nutrition and Dietetics of the University and the Clinical Facilities, which are in effect while I am a student.
Applicant's Signature
Date
MARYWOOD UNIVERSITY

Request For Faculty Recommendations

I hereby grant permission that information concerning my class performance may be released to the CP Admissions Committee from the following faculty. Please note that it is not required, but strongly suggested that one of your faculty recommendations come from a Nutrition and Dietetics faculty member. The CP director and faculty who teach in the CP cannot serve as a recommendation.
Name of Faculty:
Email address:
Courses Taken:
Name of Faculty:
Email address:
Courses Taken:
Student’s Signature:
Date:
GRADES/CREDITS: Type the grade and credits earned for all of the listed courses. If you have not yet taken one of the courses leave the spaces blank.
Major Subjects: / Grade / Credits
ND 101B: Cont Nutrition Topics/Skills
ND 101A: Cont Nutrition Topics/Skills
ND 103: Basic & Culinary Foods
ND 203: Food Science & Technology
ND 112: Nutrition I
ND 138: Food Safety
ND 223: Social & Cultural Aspects of Food
Science: / Grade / Credits
CHEM 110: Introductory Chemistry
CHEM 210: Organic Chemistry
CHEM 210L: Organic Chemistry Lab
BIOL 121: Anatomy & Physiology
BIOL 122: Anatomy & Physiology
CHEM 310: Biochemistry

Updated January 2012