Tapawingo CIT Employer/Teacher Reference Form

This reference form is for Tapawingo CIT Applicants only.
Reference form is to be completed by a recent employer or teacher.
Applicant's Name

First NameLast Name
This person has applied for a place in the Counselor-in-Training Program at Camp Tapawingo. This person will be in a close community setting in the Adirondack State Park. This program will require flexibility and maturity. Please bear this in mind as you complete this reference.
The applicant has agreed to release any person/company/agency from any liability for any damages whatsoever for information recorded on this reference form. The applicant waives her right to see this evaluation.
Thank you for your candid assessment of the applicant. This reference will be used in conjunction with other referrals, a personal interview, and an application.
How long have you known the applicant and in what capacity?
What was the nature of the work done by the applicant?
What are 3 strengths of the applicant?
What are 3 areas in which the applicant has room to grow?
In what area(s) could the applicant benefit from Tapawingo's CIT program?
Would you feel confident in hiring/rehiring this person OR having this person as a student another year?

YesNoMaybe
Please elaborate:
To your knowledge, does the applicant smoke, drink or use illegal drugs?

YesNoNot sure
Would you want your child or teenager placed under the direct charge, influence, or care of this individual?

AbsolutelyYes, with slight reservationProbably notNo
Is the applicant in good physical condition (our program is rigorous--can she run 3 miles in 30mins)?
Please select the following choices to the best of your knowledge:
Judgment
Check the words that you believe to be applicable:

MatureAdequateInconsistent
Dependability
Check the words that you believe to be applicable:

ConsistentErraticPoor
Leadership Potential
Check the words that you believe to be applicable:

NaturalLatentFollower
Cooperation
Check the words that you believe to be applicable:

ConsistentErraticPoorObstructive
Initiative
Check the words that you believe to be applicable:

ConfidentImaginativePerseveringLazy
Intellect
Check the words that you believe to be applicable:
Check the words that you believe to be applicable:

QuickTeachableAverageSlow
Personality
Check the words that you believe to be applicable:

ExtrovertWell-balancedIntrovertSelf-Confident
Adaptability
Check the words that you believe to be applicable:

FlexibleOpen-mindedRigidTactfulBlunt
Personal Presentation
Check the words that you believe to be applicable:

Well-groomedRelatively neatSloppy
Emotional Stability
Check the words that you believe to be applicable:

StableSelf-controlledEasily disturbedUnstable
What is your overall evaluation of the applicant?

Highly recommendRecommendRecommend with minor reservationsRecommend with major reservationsDo not recommend
Additional Comments:
Your Name

First NameLast Name
Position/Organization
Please choose one:

EmployerTeacher
Date

MonthDayYear
Phone Number

Area CodePhone Number
E-mail
Thank you very much for your assistance!
Should be Empty: