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BERKSHIRE HILLS - EMANUEL CAMPS
Staff Reference Form
Applicant's Name ______________________________________________________
Your Name ___________________________________ Tel # __________________
Relationship to applicant _____________________________________________
How long have you known applicant? ____________________________________
Please indicate with a check mark where you feel the applicant qualifies
regarding the following characteristics. You may note those areas which
you do not feel qualified to make a judgement with "DNA"
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Superior |
Above Average |
Average |
Below Average |
Poor |
| Mature |
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| Responsible |
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| Leadership |
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| Able to relate to peers |
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| Able to relate to children |
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| Accepts supervison |
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| Work habits |
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| Personal habits |
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| Health |
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| Communication skills |
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| Role model |
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| Commitment to Judaism |
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What knowledge do you have of the applicant's work with children?
_______________________________________________________________________
_______________________________________________________________________
What are the applicant's strengths and weaknesses?
_______________________________________________________________________
_______________________________________________________________________
Do you know of any reason this applicant should not work with
children?
_______________________________________________________________________
Additional Comments:
_______________________________________________________________________
_______________________________________________________________________
To your knowledge, has the applicant suffered any significant physical
or nervous difficulties which would interfere with his/her work with
children?
_______________________________________________________________________
To your knowledge, has the applicant ever exhibited abusive or sexually
improper tendencies towards others or has he/she ever been convicted of
a felony or misdemeanor?
_______________________________________________________________________
Signature ____________________________________ Date _________________
Internal use: Contact date: _________________ by ____________________
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