Youth Delegate Reference Form

Youth Delegate Reference Form

If selected, the youth applicant will represent both the United States and his/her own area in an international setting. The local CISV USA Chapter requests your help in identifying applicants who exhibit leadership qualities and can represent their own culture successfully.
The following is a recommendation for:*

First NameLast Name
The youth is applying for:
Name of adult completing this reference form*

First NameLast Name
Occupation
Phone of Person Giving Reference

Area CodePhone Number
Email of Person Giving Reference
example@example.com
Capacity in which you know the youth applicant*
If you are the youth applicant’s current teacher, what is your school’s name?
What is your school’s phone number?

Area CodePhone Number
Length of time you have known the youth applicant:*
Please check ALL the traits in the list below that you consider to be characteristic of the youth applicant.

matureindependentresponsibleexpressiveacceptingdiscerningshows initiativeoptimisticpessimisticresponsivecooperativecautiouscuriousattentivepracticalhelpfulparticipatesneeds coaxingcaringspontaneousreticentopen-mindedrespects adultsrespects peersfollowerleaderteam-playerfair-mindedorganizeddependentcreativequietsecurevivacioussensitiveforgetfulintrospectivefriendlyarticulateacceptedunusualsincerehealthyconfidenttolerantcompromiserintensemild-manneredpatienthurriedstudiousmotivateddisrespectfulathleticartisticoutgoinginwardintolerantflexiblefollows directionfunconscientioussharestalkativeadventurousOther
Check the FIVE adjectives in the list below that you feel describe the youth applicant's greatest strengths.

matureindependentresponsibleexpressiveacceptingdiscerningshows initiativeoptimisticpessimisticresponsivecooperativecautiouscuriousattentivepracticalhelpfulparticipatesneeds coaxingcaringspontaneousreticentopen-mindedrespects adultsrespects peersfollowerleaderteam-playerfair-mindedorganizeddependentcreativequietsecurevivacioussensitiveforgetfulintrospectivefriendlyarticulateacceptedunusualsincerehealthyconfidenttolerantcompromiserintensemild-manneredpatienthurriedstudiousmotivateddisrespectfulathleticartisticoutgoinginwardintolerantflexiblefollows directionfunconscientioussharestalkativeadventurousOther
Use this space to elaborate on any of the traits circled above or to share any concerns. Keep in mind that we are looking for youth who complement each other when forming program delegations. There is no set profile of a “typical” or “ideal” youth delegate.
Do you know of any special talents or experiences that would help this youth applicant contribute to an international program?
To the best of your knowledge, does this youth applicant have any emotional or behavioral characteristics that would interfere with his/her successful completion of a CISV program? *
Behaviors that are never acceptable in any CISV program include illegal acts, alcohol/drug abuse, dishonesty, prejudice or intolerance, violence or lack of self-control, sexual contact, verbal abuse of others, and inability to handle a reasonable amount of stress. If you have seen the youth applicant exhibit such behaviors, please explain in the space below
The information provided above has been thoughtfully and honestly given, based on my knowledge and perception of the youth applicant. I understand that the information will be kept confidential and will be used by the local CISV Chapter in the evaluation of the youth applicant.*

check this box to indicate agreement with the above statement
Signature of Referring Person

Clear
Date of Signature of Referring Person

MonthDayYear
Should be Empty: