Confidential Reference Form

Reference cannot be filled out by a relative or peer.

Applicant's Name*
First Last
Your Name*
First Last
What is your relationship with the applicant?*
- Family friend
- Mentor/Small Group Leader
- Pastoral Pastor
- Youth Pastor
- Coworker
- Supervisor
- Employer
How many years have you known the applicant?*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10+
On what basis do you know this person?*
- One-to-One
- Small Group (1-10)
- Medium Group (10-25)
- Large Group (25+)
What position are they applying for?*
What are your expectations for the applicant's work?*
- Poor
- Average
- Good
- Superior
Please check any traits below which characterize this person:*
- Easily Irritated
- Fun
- Intolerant
- Argumentative
- Humorous
- Nervous
- Responsible
- Compassionate
- Impatient
- Easily Angered
- Discouraged
- Happy
- Bull Headed
- Pleasant
- Easily Embarrassed
- Depressed
- Dishonest
- Friendly
- Moody
- Complainer
- Cooperative
- Cannot take a Joke
- Energetic
- Conscientious
- Patient
- Committed
- Influential
- Creative
- Always Asking "Why"
- Sullen
- Positive
- Tense
- Loving
- Critical of Others
- Legalistic
- Frequently Worries
- Intelligent
- Giving
- Caring
- Prompt
- Sensitive
- Task-Oriented
- Good Common Sense
- People-Oriented

Mark the checkbox that best represents the applicant each category (1 = lowest, 10 = highest)*

	N/A	1	2	3	4	5	6	7	8	9	10
Quality of Work
Punctuality
Demeanor
Initiative
Leadership
Safety
Interpersonal Relationships
Follow Up
Teachability
Respects Leadership
Team Worker
Conflict Resolution
Capacity to Work with Youth/Children

Please comment on the applicant's spiritual life:*
Would you completely trust this individual to guide and care for your child in a group and/or one-on-one setting?*
- Yes
- No
Based off of your relationship with the applicant, please make a selection.*
- I strongly recommend this applicant.
- I recommend this applicant.
- I recommend this applicant with reservation.
- I do not recommend hiring the applicant.
If you selected "I recommend with reservations" or "I do not recommend", please give your reasons below.
Contact Information
Your Address*
Street Address City State / Province / Region ZIP / Postal Code
Your Email*
Your Phone Number*
What is the best day for us to call you?*
- Select All
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
What time of day is best for you?*
- Select All
- Morning
- Afternoon
- Evening
Email
This field is for validation purposes and should be left unchanged.

Contact Information