Reference Form
Please complete this form neatly to help us determine if this prospective staff member will be a positive role model for young people. Please be further advised that all information will be kept confidential.

Applicant's Name:
How long and in what capacity have you known the applicant?

If you employed the applicant, would you rehire?
Yes
No
If no, for what reason?

Would you leave your child (or a child in your like) under the influence of this applicant for an extended period of time?
Yes
No
Please explain if the answer is no.

Do you have any reason to believe the applicant has been or is a user of illegal drugs?
Yes
No
Do you have any reason to believe the applicant is excessive or irresponsible user of alcohol?
Yes
No
Responsibility
Adaptability/Flexibility
Communication Skills
Creativity
Enthusiasm/Energy
Independence
Initiative
Integrity/Honesty
Judgment/Common Sense
Leadership Skills
Maturity
Professional Appearance
Self-Confidence
Work Ethic

Please comment on any of your above responses if necessary:

Reference's Name:
Position:
Company:
Relationship to Applicant:
Daytime Telephone Number:
Email Address:

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