Applicant's Name

First Name

Last Name

Reference's Name

First Name

Last Name

Reference's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference's Phone

(###)

###

####

Reference's Email

1. What is your relationship to the Applicant?

2. How long have you known the Applicant?

3. How well do you know the Applicant?

4. How would you describe the Applicant?

5. What are some ways you’d like to see this person grow or develop?

6. Have you observed this person in a frustrating situation? What happened?

7. Do you know of any characteristics that would negatively affect the applicant’s ability to work with children, youth, or vulnerable persons?

8. Do you have any knowledge that the applicant has ever been convicted of a crime? If so, please describe:

9. Any other information that you would like to provide about this applicant?

To my knowledge, all information provided is true and correct.

Date of Form Completion

YYYY

Bridge Youth Center - Personal Reference Form