Send Electronic Application Or Questions Regarding Application To

IDDA Achievement Award Application DEADLINE: Friday March 21, 2014 at 11:59pm Send electronic application or questions regarding application to: Kristi Coughlin: [email protected]

IDDA will award a minimum of two (2) scholarships valued at $250 to deserving nutrition students or dietetic interns who demonstrate a strong potential to succeed as a dietitian. Funds will be awarded based on current academic standing, involvement within the profession (either on campus or within the community), and their potential to excel professionally.

PERSONAL INFORMATION (please print or type): Name: Date: Present Address: Street Address Email: City Zip Code Phone No: ( ) - Alt Phone No: ( ) -

MEMBERSHIP STATUS (applicant must be a current ADA/CDA/IDDA member) ADA Number: Are you an active member of Inland District Dietetic Association? Yes, since If you are not currently a member you may join now. Have you received IDDA Award in the past? Yes No If yes, what year?

EDUCATION: I am attending internship/college/university:

STUDENT STATUS: (check only one student status category that is applicable to your present situation) Undergraduate Dietetic Intern Postgraduate Sophomore Program Emphasis: Emphasis: Junior Senior

Anticipated date for completion of degree/program: Month Year

IDDA STUDENT ACHEIVEMENT AWARD 2014 Page 1 of 4 WORK EXPERIENCE(S): Current and previous experiences related to Nutrition and Dietetics Organization Supervisor Position Title Start & End Dates Hours/week

Key Responsibilities:

Organization Supervisor Position Title Start & End Dates Hours/week

PROFESSIONAL/COMMUNITY/VOLUNTEER ACTIVITIES: Include organizations, memberships, offices held, committee participation, honor received and major accomplishments, additional point will be given for participation in IDDA events.

PUBLICATIONS AND/OR PROFESSIONAL PRESENTATIONS (if applicable):

STATEMENT OF PROFESSIONAL GOALS/IDEALS Please attach a letter indicating your motivation to enter the profession of dietetics and your career/ professional goals. Also indicate how this achievement award will assist you in obtaining the goal(s) that you indicated. When submitting the statement, please include your first and last name on the top right side of the document.

Submission Check List: Application must be received via email by Friday March 21, 2014 at 11:59pm. Completed application (first two pages) ADA Membership number and school/program name included on the first page of the application Statement of professional goals as above GPA verification with signature (this must be scanned and sent electronically as PDF document) 2 letters of recommendation sent electronically with application or directly from letter writer All documents must be received via email at [email protected] by the deadline

IDDA STUDENT ACHEIVEMENT AWARD 2014 Page 2 of 4 ACADEMIC INFORMATION To be completed by the student and verified by program director (see below).

Student Name:

College/University Attended From: To: Major GPA Month/Year Month/Year

Overall Grade Point Average (GPA): on a 4.0 scale

Dietetic Coursework GPA:

Number of units completed:

FACULTY VERIFICATION OF GPA To be completed/signed by program director.

I certify that I have reviewed the above student’s GPA.

Date: Faculty Signature FORMTEXT Faculty Name (Printed)

Faculty Title Phone: ( ) - ext.

IDDA STUDENT ACHEIVEMENT AWARD 2014 Page 3 of 4 LETTERS OF RECOMMENDATION: Please give this section to the persons writing your letter.

Applicant:

The above student or intern is applying for an achievement award from the Inland District Dietetic Association. In order to support their application, they need 2 letters of recommendation. You have been identified as a reference for this student/intern. Could you please submit a letter of recommendation for him/her that addresses the following?

 How long have you known the applicant and in what capacity?  How would you describe the applicant as a potential dietetic colleague?  What qualities distinguish this applicant from other students, interns or colleagues?  Any other information that you would like to include regarding this applicant.  Your name, title, contact information, etc.

Please return the letter to the applicant, or directly to me at [email protected] by Friday March 21, 2014.

Thank you, Kristi Coughlin

Kristi Coughlin, MS, RD Nominating Committee Chair California Dietetic Association, Inland District

IDDA STUDENT ACHEIVEMENT AWARD 2014 Page 4 of 4