VSSM PERSONAL REFERENCE FORM

VSSM PERSONAL REFERENCE

To be completed by someone who can best describe your character
Student's Name *
YOUR Name *
Date of Birth

Day Month Year
Phone Number

Area Code Phone Number
E-mail Address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Gender

Male Female
Do you recommend this student?

Highly Recommend Recommend Do not recommend
Can you please explain your recommendation:
Please describe any physical or emotional conditions or special attention needed that this person might require:
How long have you known the applicant?
Relationship to the applicant:
How well do you know him/her? Please explain:
To your knowledge, has the applicant made a personal commitment to Jesus Christ?

Yes No I'm not sure
To your knowledge, has the applicant been baptized in the Holy Spirit?

Yes No I'm not sure
To your knowledge, does the applicant use tobacco? If yes, please explain:
To your knowledge, does the applicant drink alcohol in excess? If yes, please explain:
In what form of Christian service has the applicant participated regularly (Sunday School Teacher, Youth Leader, nursery Worker, etc.) ? Please explain:
What do you consider to be the applicant's strengths?
What do you consider to be the applicant's weaknesses?
Which characteristics best describe the applicant? Please check all that apply and give a brief description:
Christian Commitment:
Social Adaptability:
Cooperativeness:
Integrity and Honesty:
Responsibility:
Mental Ability:
Physical Health:
Initiative:
Christian Character:
Personal Appearance:
Leadership:
Reliability:
Other Comments:
Should be Empty: