Street City Province Postal Code

Referee’s Telephone No: _______________________ E-mail: ___________________

Applicant’s Name: ______________________________________________________

The above named applicant is applying for a position as a counsellor at one of the Diocese’s summer camps. These camps run programs for children aged 4-16. As a Christian camp, we try to help prepare people physically, socially, mentally and spiritually to take their place as Christians in today’s world. Please answer the following questions to assist us in our consideration of this applicant.

Please circle the number which best describes the applicant

1 indicates a LOW rating, 5 a HIGH rating

Ability to accept responsibility 1 2 3 4 5

Ability to lead 1 2 3 4 5

Is a self-starter 1 2 3 4 5

Relates well to children 1 2 3 4 5

Gets along well with others 1 2 3 4 5

Is reliable 1 2 3 4 5

Is willing to submit to authority 1 2 3 4 5

Is emotionally stable 1 2 3 4 5

Moral character 1 2 3 4 5

Is enthusiastic 1 2 3 4 5

Joins in well 1 2 3 4 5

Can share their faith easily 1 2 3 4 5

Is able to take criticism 1 2 3 4 5

If you had the responsibility, would you hire this individual? _________

Please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any other information that would be helpful in evaluating this application:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In what capacity have you known the applicant? ______________________________________

How long have you known the applicant? ____________________________________________

______________ _____________________________________________

Date Signature of referee

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