Reference Form

This form should be completed by an applicant's teacher, professor, academic advisor, coach or past/present employer.

Friends and relatives will not be considered.

Since the candidate is going to be working with children, we feel it is of the utmost importance to screen each candidate extensively. We would be very grateful if you could take a few minutes to answer the following questions so that we may ensure a safe, happy and healthy environment for our campers.

Please complete all sections below.

Thank you.

(Please note, fields marked with * must be completed).

Applicant's Information:
		First Name*	Last Name*	Cell Phone Number	Position Applying For

Please select the degree to which the applicant demonstrates the following qualities:
1.	Demonstrates willingness to learn and grow
2.	Ability to express self
3.	Ability to organize responsibilities and tasks
4.	Reliability and promptness in handling tasks
5.	Punctuality and regularity in attendance
6.	Ability to function as a part of a team
7.	Ability to relate well to co-workers
8.	Degree of flexibility and ability to adapt
9.	Ability to accept evaluation of performance
10.	Handles stressful situations successfully
11.	Demonstrates understanding of children
12.	Demonstrates enthusiasm and creativeness
13.	Demonstrates efficiency in routine matters
14.	Ability to relate and give guidance to children
15.	Evidences loyalty to job and supervisors
16.	Maintains confidentiality of information

Please complete the following questions below:

How long have you known the applicant?

My contact with the applicant is/was:

Almost Daily Weekly Infrequently

Information given on the application is based on:

Personal Acquaintance Co-Worker/Employee Student in my class Other

Have you observed this person working with children? Yes No

Comments:

Does the applicant accept extra duties willingly?

Yes No N/A

Is the applicant a person you would like to care for/work with a child to whom you are very close to?

Yes No N/A

With your present knowledge, would you employ or re-employ this applicant?

Yes No N/A

To your knowledge, has this applicant ever failed to have a contract renewed, resigned to avoid being terminated, or been terminated from employment?

Yes No N/A

Does this applicant have any moral or social peculiarities or habits which yould make him/her unsuitable as a camp counselor?

Yes No N/A

May we contact you regarding the applicant?

Yes No

Please check all of the words which best describe the applicant. Please add any other.

Outgoing	Leader	Trustworthy	Serious	Shy
Complacent	Confident	Reserved	Follower	Tolerant
Cooperative	Inquisitive	Energetic	Assertive	Loyal
Cheerful	Mature	Creative	Sensitive	Competent
Thorough	Quiet	Concerned	Friendly	Initiator
Self-Centered	Dedicated	Well-Groomed	Aggressive	Innovative
Determined	Caring	Honest	Motivated	Congenial
Dependable	Relaxed	Enthusiastic	Probing
Other		Other

Please select your overall rating of this applicant

Unsatisfactory Below Average Average Above Average Outstanding

Please Provide us with the following personal information:

Reference Name*

Position*
College/Company/Dept./School*

Street
City
State
Zip
Country

Contact Phone Number*
Email*

Comments

By typing AGREE in this box, and by electronic submission of this application,
I certify that all the statements and information on this reference are accurate and complete.

Type the word 'agree' here*: