References

Reference Form
Your Full Name (Reference Contact)
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of applicant (that included you as a reference)
Position
He/she has given your name as a person to be (Position) contacted for information regarding his/her character, suitability to work with children and previous or prospective job performance. Please answer the following questions and provide any additional comments that could be helpful. Your response will be kept confidential.
How long have you known this person
What is/was your relationship with this person?( friend, employer, pastor, neighbor,etc)
In your opinion ,Is this person Dependable?

YesNo
In your opinion , Is this person Honest?

YesNo
In your opinion Is this person Even-Tempered?

YesNo
Comments:
To your knowledge, does this person Use Drugs?

YesNo
To your knowledge, does this person Drink Excessively?

YesNo
To your knowledge, does this person Use abusive language?

YesNo
Comments:
If you are/were an employer of this person describe the type of work the person does/did and the quality of the work he/she performed. What was the reason for the person leaving your employment, if applicable
If you have young children, would you leave your own child/children in the care of this person?

YesNo
If no, please explain
To your knowledge, does this person have qualities, traits, or abilities that make him/her particularly suitable to care for children?

YesNo
Please explain
Do you know of any reason why this person might not be suitable to care for children?

YesNo
If yes please explain
If you have any additional comments about this person you feel would be useful when considering his/her application for employment in a child care facility, please state below.
Signature

Clear
Date

MonthDayYear
Date
Telephone number
Name of person requesting information
Name of child care facility home center
City
Street
State
Zip Code
If you prefer not to provide a reference for this person, please sign here and return this form.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Reference Form