References

Your Full Name (Reference Contact)

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?

In your opinion , Is this person Honest?

In your opinion Is this person Even-Tempered?

Comments:

To your knowledge, does this person Use Drugs?

To your knowledge, does this person Drink Excessively?

To your knowledge, does this person Use abusive language?

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?

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?

Please explain

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

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

Date

Telephone number

Format: (000) 000-0000.

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

Date

Reference Form