Name of Applicant
*
First Name
Middle Name
Last Name
Reference Name (Your Name)
*
First Name
Middle Name
Last Name
Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email
example@example.com
Thank you for answering the following questions as they relate to your knowledge of the above-named applicant.
How long have you known this person?
*
In what capacity?
*
Do you know this person on a:
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One on one basis
Small group basis (1-29)
Medium group basis (30-99)
Large group basis (100+)
If you employed this applicant, would you rehire them?
Yes
No
Other
In your relationship with the applicant have they been involved in any programs involving adults or children? If yes, please describe their involvement.
*
Please mark the appropriate circle based on your experience with the applicant.
*
Rows
Poor
Fair
Average
Above Average
Excellent
Unknown
Teachable
Promptness
Follows Instructions
Outgoing
Emotional Balance
Capacity to Work with Children
Fulfills Obligations
Sense of Humor
Follow-Through Ability
Energetic
Trustworthy
Gets Along with Others
Tact
Leadership Abilities
Friendly
Moral Reputation
Truthfulness
Respectful
Flexibility
Dependability
If possible, please comment on the applicant's spiritual life.
Assess the applicant's ability to work in a group setting - is he/she a team player? Can he/she follow the rules?
*
What words or phrases immediately come to mind when describing the applicant?
*
Would you completely trust this individual to guide and care for your child in a one-on-one setting?
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Yes
No
To your knowledge, has there been any reports involving misconduct with vulnerable adults or children against the applicant?
*
Yes
No
If yes, please describe the report.
I would:
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Strongly Recommend
Recommend
Recommend with some reservations
NOT Recommend
What specific reason would you give for hiring or not hiring this applicant?
Signature of Reference
*
Date
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/
Month
/
Day
Year
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