Abstract: . . .  Program ____________________________________________________________________________________________ Last Name First Middle/Maiden Please indicate your relationship with this individual: ____Teacher in one class ____Department head ____Employer ____Teacher in several classes ____Advisor ____Other (Specify:_________________) PLEASE CHECK Low/Poor 1 2 Average 3 4 Out- standing  . . .
. . .  6 DEPARTMENT OF NUTRITION AND DIETETICS I.U. School of Health and Rehabilitation Sciences- COLEMAN 224 1140 West Michigan Street INDIANAPOLIS, INDIANA 46202-5119 Leadership Education Excellence in Pediatric Nutrition Program ____________________________________________________________________________________________ Last Name First Middle/Maiden Please indicate your relationship with this individual: ____Teacher in one class . . .
. . .  German measles Mononucleosis Headaches, frequent Mumps List serious injuries and hospitalization (include dates) List surgical operations (include dates) List medication or drugs used regularly List physical handicaps or other limitations Menstruation: Began _________ Regular__________ Irregular__________ Profuse__________ Do you need to restrict your activities? No ___ Yes ___ How______________________________ IMMUNIZATION RECORD Measles . . .
. . .  Ability to get along with people Dependability Reaction to advice and objective criticism Leadership potential Poise, self-confidence Personal appearance Physical health and vitality Indications of success in dietetics COMMENTS: Please type or print (use additional sheet if needed) BY:___________________________________________________________ Name Position ___________________________________________________________ . . .
. . .  ___________________________________________________________ Date Signature Page 6 6 DEPARTMENT OF NUTRITION AND DIETETICS I.U. School of Health and Rehabilitation Sciences- COLEMAN 224 1140 West Michigan Street INDIANAPOLIS, INDIANA 46202-5119 Leadership Education Excellence in Pediatric Nutrition Program ____________________________________________________________________________________________ Last Name First Middle/Maiden Please indicate . . .
. . .  qualified to give pertinent information related to professional abilities and potential. Please use the forms below. A letter also may accompany the reference form. 4. Nonrefundable application fee $50. Please make check payable to: Indiana University In submitting my application for review, I agree to the following: If I am granted admission to the program and barring no unforeseen circumstance, I will continue my career plans as indicated in the application. If circumstances . . .
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