Childcare Reference Form

Full Name*
First Name Last Name
Email*
Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Applicant you are referencing*
First Name Last Name
Email address of the applicant (make sure that this is correct)*
Your relationship to the applicant*
- Pastor
- Youth Pastor
- Employer
- Friend
- Co-Worker
- Mother
- Father
- Brother
- Sister
- Aunt
- Uncle
Rate each of the following
1 (poor) - 5 (excellent) or Unknown. Note: These are not judgment statements, but ratings based on your observations and interactions with the applicant.
Ability to disciple and mentor others*
- 1
- 2
- 3
- 4
- 5
- Unknown
Administration and organization*
- 1
- 2
- 3
- 4
- 5
- Unknown
Christian witness in the community*
- 1
- 2
- 3
- 4
- 5
- Unknown
Conduct with the opposite sex*
- 1
- 2
- 3
- 4
- 5
- Unknown
Conflict resolution*
- 1
- 2
- 3
- 4
- 5
- Unknown
Dependability*
- 1
- 2
- 3
- 4
- 5
- Unknown
Emotional stability*
- 1
- 2
- 3
- 4
- 5
- Unknown
Evidence of the fruit of the Spirit*
- 1
- 2
- 3
- 4
- 5
- Unknown
Freedom from sin and addictions*
- 1
- 2
- 3
- 4
- 5
- Unknown
Home environment*
- 1
- 2
- 3
- 4
- 5
- Unknown
Industriousness and work ethic*
- 1
- 2
- 3
- 4
- 5
- Unknown
Leadership skills*
- 1
- 2
- 3
- 4
- 5
- Unknown
Mercy for the hurting and needy*
- 1
- 2
- 3
- 4
- 5
- Unknown
Relating to people from other cultures*
- 1
- 2
- 3
- 4
- 5
- Unknown
Sensitivity to others*
- 1
- 2
- 3
- 4
- 5
- Unknown
Social and relational skills*
- 1
- 2
- 3
- 4
- 5
- Unknown
Willingness to serve*
- 1
- 2
- 3
- 4
- 5
- Unknown
Comments*
Applicant's effect on community*
- Builds
- Loves and lives within it
- Drains energy from
- Damages or destroys
Applicant's relationship to authority*
- Appreciative of input and guidance
- Quiet submission
- Begrudging obedience
- Resentful or rebellious
Rate each of the following
1 (not a problem) - 5 (serious concern) or Unknown. Note: These are not judgment statements, but ratings based on your observations and interactions with the applicant.
Careless*
- 1
- 2
- 3
- 4
- 5
- Unknown
Critical*
- 1
- 2
- 3
- 4
- 5
- Unknown
Depressed*
- 1
- 2
- 3
- 4
- 5
- Unknown
Divisive*
- 1
- 2
- 3
- 4
- 5
- Unknown
Easily embarrassed*
- 1
- 2
- 3
- 4
- 5
- Unknown
Easily offended*
- 1
- 2
- 3
- 4
- 5
- Unknown
Immature*
- 1
- 2
- 3
- 4
- 5
- Unknown
Impatient*
- 1
- 2
- 3
- 4
- 5
- Unknown
Impulsive*
- 1
- 2
- 3
- 4
- 5
- Unknown
Intolerant*
- 1
- 2
- 3
- 4
- 5
- Unknown
Moody*
- 1
- 2
- 3
- 4
- 5
- Unknown
Prejudiced*
- 1
- 2
- 3
- 4
- 5
- Unknown
Proud*
- 1
- 2
- 3
- 4
- 5
- Unknown
Selfish*
- 1
- 2
- 3
- 4
- 5
- Unknown
Worried*
- 1
- 2
- 3
- 4
- 5
- Unknown
Comments*
Has the applicant been involved in abusive relationships, as a victim or an abuser?*
How does the applicant relate with children?*
How comfortable would you be with the applicant taking care of your children for 6 weeks?*
Best time/days to call (if necessary).*
Comments
Do you know others who might appreciate more information about the Ministry Training Center? If so, please list their names and contact information below.
After you click "Submit" you will receive an email confirmation and be redirected to our web page about the Long-Term Orientation.

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