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The aforementioned applicant has shown interest in becoming involved in Youth Ministry at Calvary Chapel Golden Springs and has given your name as a reference. We love our youth and feel a responsibility to take every precaution to safeguard them.


We appreciate your time and effort in helping us by filling out this form, and sending it back to us.


Please enter the Applicant's Full Name


1) How long have you known the applicant?


2) In what relationship:
FRIENDEMPLOYERPASTORNEIGHBOR(OTHER)

(If other, please explain)

3) As far as you know, has this person had any history of child abuse or molestation? NoYes

(If Yes, please explain)

THIS REFERENCE FORM WILL NOT BE SHOWN TO, OR DISCUSSED WITH, THE APPLICANT.

Check any characteristics or traits, which you have noticed in the applicant:

TRUTHFULLOVINGPATIENTKINDGENTLETHOUGHTFULFRIENDLYFAITHFULGOODPEACEMAKEROPTIMISTICCHEERFULRELIABLELIKABLEQUIETCOMPASSIONATEADAPTABLECOMPLIANTIMPATIENTRUDEGOSSIPSSELF-ABSORBINGDOMINEERINGUNRELIABLEDIVISIVEPESSIMISTICMELANCHOLYOUTSPOKENARGUMENTATIVEUNTEACHABLESHORT TEMPEREDRIGID

Have you ever observed the applicant with youth? NoYes
If Yes, what was your observation? EXCEPTIONALLY GOODVERY GOODGOODFAIRPOOR

What do you believe to be the applicant's motivation in applying to the Youth Ministry?

How would you rate the applicant's potential success in the Youth Ministry?
EXCEPTIONALLY GOODVERY GOODGOODFAIRPOOR
Comment:

Do you have any reservations in recommending this person?
NoYes

If Yes, please explain:

Please give your frank evaluation of this person by checking one or more items under each of the headings below. Do not check items in areas in which you feel uncertain or which you have had no opportunity to observe.

(a) PHYSICAL CONDITION
Frequently incapacitatedSomewhat below parFairly healthyGood healthExcellent health
(b) SOCIABILITY OR FRIENDLINESS
Avoided by othersTolerated by othersLiked by othersWell-liked by othersSought by others
(c) ACHIEVEMENT (ABILITY TO FORMULATE, EXECUTE, & CARRY PLANS TO CONCLUSION)
Does only what is assignedStarts but does not finishMeets average expectationsResourceful and effectiveSuperior creative ability
(d) LEADERSHIP (ABILITY TO INSPIRE OTHERS & MAINTAIN THEIR CONFIDENCE)
Makes no effort to leadTries but lacks abilityHas some leadership promiseGood leadership abilityUnusual ability to lead
(e) TEAMWORK (ABILITY TO WORK WITH OTHERS)
Frequently causes frictionPrefers to work aloneUsually cooperativeAble to work with those of different personalityMost effective in teamwork
(f) RESPONSIVENESS (TO FEELINGS AND NEEDS OF OTHERS)
Slow to sense how others feelReasonably responsiveUnderstanding and thoughtfulResponds with unusual insight
(g) EMOTIONAL ADJUSTMENT
Yields to urges or cravingsTense, fearful, worriedEasily angered, easily frustratedDownhearted, blue, depressedMaintains balance, self-controlled
(h) TEACHABLE
Rigid, argumentativeHighly opinionatedOpen-mindedWilling to receive instructionEager to receive instruction
(i) PERSEVERANCE (IN COMPLETING TASKS)
Gives up easily or easily discouragedNeeds encouragement to perseverePersists in most circumstancesPersists even under adversity
(j) SELF-IMAGE
InsecureInferiority complexSelf-confidentMay be prone to boastModest, true estimate of self


Do you have any reason to doubt applicant's personal integrity?
NoYes

If Yes, please explain:


Reference Name:

Email:

Applicant's Full Name:

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