Reference Response Information

To whom it May Concern: The above individual, who has expressed an interest in working with children or youth in our ministry, has listed you as a reference. In order for our organization to properly evaluate the qualifications of this worker candidate, we would like you to complete this form with your honest opinions and impressions of the candidate. The applicant has agreed to release any person/company/agency from any liability for any damages whatsoever for any information provided by this reference. The applicant waives his or her right so see this evaluation. Once completed, please return this form to our organization in the enclosed envelope. Thank you for your assistance in this regard.

Name

Regarding (applicants name)

Todays Date

How long have you known the above individual?

In what capacity have you come to know this individual? (i.e. coworker, neighbor, friend, etc.)

If this person had been employed by you, what were the dates of employment?

In your opinion, is the above worker candidate fully qualified to work with children and youth?

Yes No (If no, explain below)

What concerns, if any, would you have in allowing this individual to work with children or youth?

Are you aware of anything in the candidate’s background, personality, or behavior that could in any way pose a threat to children or youth?

Yes (If yes, explain below) No

What is your overall evaluation of the applicant?

Additional comments or explanations:

Address

By typing my name below, I certify that the information contained in this application is correct to the best of my knowledge.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Today's Date

If you have any questions please call our office at 570.386.2154

Reference Response Information

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Reference Response Information

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