Allied Health Programs Request for Academic Rating Form
The Academic Rating Form is utilized by the Bossier Parish Community College Allied Health Programs in the clinical selection
process. Academic Rating Forms are not available to students. Academic Rating Forms are e-mailed to only the instructor(s)
indicated by the student. The student must provide the e-mail address and contact information for each indicated
It is STRONGLY SUGGESTED that the student submit their Request for Academic Rating Form as soon as possible. Upon
receipt of a Request for Academic Rating Form, the indicated instructor(s) will be contacted by e-mail and asked to complete an
Academic Rating Form on the student and/or it will result in an archived academic rating form that was completed by your
ALHT 109 instructor being forwarded to the selection committee.
It will be the student's responsibility to follow up with the instructor indicated on the Request for Academic Rating Form to
ensure they have completed and submitted the Academic Rating Form by the program's application deadline. Failure to have the
Academic Rating Form submitted by the program application deadline may result in the student's application becoming
ineligible for consideration.
To confirm receipt of the completed Academic Rating Form, you can contact Tonia Sharp either by phone at (318) 678-6110 or
by email at
To submit your Request for Academic Rating, print the form, sign the consent to release information part then return it to Tonia
Bossier Parish Community College
Attn: Tonia Sharp Academic Rating Request
6220 East Texas Street
Bossier City, LA 71111
Consent to Release Information
I, _____________________________, give the instructor I have indicated on the Request for Academic Rating Form,
permission to release my Academic Rating to the selection committee(s) of the clinical program(s) to which I am applying.
_ Date:
Applicant Information
To which program(s) are you applying at this time? (check all that apply) Occupational Therapist Assistant
Physical Therapist Assistant
______________________________________________ Applicant’s CWID#: ______________________
Phone number: _____________________________________ Address: _________________________________________
E-mail: _________________________________ City, State, Zip: _______________________________________________
ALHT 109 Information
Instructor’s Name:__________________________________ Semester & Year of ALHT 109 ___________________________
Phone Number: ____________________________________ Instructor’s E-mail: _________________________________
Instructor (only use if ALHT 109 more than 5 years old)
Instructor: ____________________________________ Instructor’s Email: ___________________________________
Phone number: _________________________ Name of College/University if different than BPCC: __________________
Semester & Year of instruction: ___________________ Course of Instruction: ______________________________________
click to sign
click to edit