Scholarship Reference Form

Please use the provided survey to submit a recommendation for a HIMSS Foundation Scholarship applicant. The HIMSS Foundation annually awards scholarships to HIMSS student members who have achieved academic excellence and have the potential to be future leaders in the healthcare information and management systems industry.

Please note: The application will time out after 20 minutes of inactivity. All reference letters for 2012 Scholarship applicants are required to be submitted by October 15, 2012.

*Applicant Name:

*Reference Name:

*Reference Title & Organization:

*Reference Email:

*Relationship to applicant:

* Briefly describe the skills/strengths/characteristics of the applicant:

* Describe a project or initiative in which the applicant went above and beyond expectations:

Please provide any additional details or information as to why you believe this applicant is deserving of a HIMSS Foundation Scholarship: