Clone of 2026 Staff Reference Form

Northern Virginia 4-H Educational Center

Staff Reference Form

You have been listed as a reference by someone who has applied for a position at Northern Virginia 4-H Educational Center as a camp staffer.

The position requires a high degree of responsibility, iniative, hardwork, integrity, maturity, and organization. We would appreciate your honest response to the questions listed below. Your input is a valuable tool in helping us to select the best young adultsto serve as role models, teachers, and mentors to youth camping with us this this summer.

Your input will remain confidential.

Tatyana Yates,
Program Director
tatyana@vt.edu
(540) 635-7171

Your name:

First NameLast Name

Your phone number:

Area CodePhone Number

Your email:

example@example.com

Name of the Applicant you are providing the Reference for:

First NameLast Name

Please describe your relationship to the applicant and your knowledge of the applicant's qualifications:

Please describe the applicant's ability to work with those that are different from them interpersonally or professionally:

Please describe the applicant's written & oral communication skills.

Please describe the applicant's ability to handle conflicts.

What strengths does the applicant have that would make him/her a good candidate for employment at the Northern Virginia 4-H Center?

Are you aware of any criminal record or other information that might make the candidate unsuitable for working with your children? Does the applicant possess any qualities that would make them unfit for working with youth, teens, and other adults? If yes, please explain. If you have no concerns, please comment n/a.

Please indicate the quality of each of the following characteristics in the applicant.

Personality

	1	2	3	4	5

1 is Poor, 5 is Excellent

Character

	1	2	3	4	5

1 is Poor, 5 is Excellent

Dependability

	1	2	3	4	5

1 is Poor, 5 is Excellent

Leadership

	1	2	3	4	5

1 is Poor, 5 is Excellent

Initiative

	1	2	3	4	5

1 is Poor, 5 is Excellent

Emotional Intelligence

	1	2	3	4	5

1 is Poor, 5 is Excellent

Enthusiasm

	1	2	3	4	5

1 is Poor, 5 is Excellent

Judgement

	1	2	3	4	5

1 is Poor, 5 is Excellent

Honesty

	1	2	3	4	5

1 is Poor, 5 is Excellent

Cooperation

	1	2	3	4	5

1 is Poor, 5 is Excellent

Ability to work independently

	1	2	3	4	5

1 is Poor, 5 is Excellent

Response to supervision

	1	2	3	4	5

1 is Poor, 5 is Excellent

Dedication

	1	2	3	4	5

1 is Poor, 5 is Excellent

Respect for others

	1	2	3	4	5

1 is Poor, 5 is Excellent

If you were in a position to do so, would you employ the applicant? If not, why not?

Please make any additional comments that would help us better determine the knowledge, emotional intelligence, initiative, attitude, and the skills the applicant possesses.

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