Reference Form

An acquaintance of yours has applied for a position as a Counselor at Triple C Camp. Because of the important responsibilities in a program involving children, your honest and thoughtful appraisal is of the utmost importance. The information you provide is appreciated and confidential.
Name of Applicant*
Attendance/Punctuality*
- Excellent
- Good
- Fair
- Poor
Honesty/Dependability*
- Excellent
- Good
- Fair
- Poor
Work Habits/Organization*
- Excellent
- Good
- Fair
- Poor
Adaptability/Flexibility*
- Excellent
- Good
- Fair
- Poor
Attitude*
- Excellent
- Good
- Fair
- Poor
Relationship With Co-Workers*
- Excellent
- Good
- Fair
- Poor
Leadership Abilities*
- Excellent
- Good
- Fair
- Poor
Ability To Work In Groups*
- Excellent
- Good
- Fair
- Poor
Responsibility*
- Excellent
- Good
- Fair
- Poor
Personal Appearance*
- Excellent
- Good
- Fair
- Poor
Ability To Relate To Children*
- Excellent
- Good
- Fair
- Poor
Children’s Response To Applicant*
- Excellent
- Good
- Fair
- Poor
Ability To Control Emotions*
- Excellent
- Good
- Fair
- Poor
Sense Of Humor*
- Excellent
- Good
- Fair
- Poor
Would you be willing to leave your children under the applicants supervision for a period of up to eight weeks? Please explain*
Does the applicant show signs of any behavior which would cause concern when working directly with children?*
How long have you known the applicant?*
What is your relationship to the applicant?*
Any general recommendations or comments?*
Your Name*
Your Email*
Position*
Company*
Thank you for your honest evaluation!

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Phone: 434.293.2529
Fax: 434.293.2235

920 Camp Road,
Charlottesville, VA 22902

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