Reference Form ApplicantApplicant Name* First Last Applicant Desired Position*ReferentReferent Name* First Last Referent Phone*Referent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referent Occupation*Referent Employer*The above named applicant has applied for a summer staff position at Lake Ann Camp. The Lake Ann Camp style of camping involves a great deal of hands on contact between staff and campers. We have a very serious attitude about the type of staff that we hire. They must be able to show a consistent godly attitude even under adverse circumstances. Thank you for conscientiously helping us to select those people who can consistently impact the young people entrusted to our care.How long have you known the applicant?*In what capacity?*How well do you know the applicant?*Very WellWellCasuallyQualificationsPlease answer the questions below.Responsibility*Excellent - diligently follows through on tasksGood - follows through on tasksAverage - usually follows through on tasksPoor - needs to be told what to doInitiative*Excellent - will look for things to doGood - will do things that need to be doneAverage - will do the obvious if there is needPoor - needs to be told what to doIndustry*Excellent - puts forth the extra for excellenceGood - will put in a fair day's workAverage - works enough to get byPoor - lazyLeadership*Excellent - a leader of leadersGood - contributes positivelyAverage - usually well-balancedPoor - passive, observing and indifferent; negatively influencesEmotional*Excellent - diligently follows through on tasksGood - follows through on tasksAverage - usually follows through on tasksPoor - needs to be told what to doJudgment*Excellent - consistently makes wise decisionsGood - makes good decisions in most situationsAverage - makes good decisions in optimal situationsPoor - hasty or indecisiveMotivation*Excellent - exceptional stable and consistentGood - well-balanced in most situationsAverage - usually well-balancedPoor - excitable or unresponsiveCooperation*Excellent - deeply sensitive to others, to allGood - generally concerned for others, to mostAverage - cooperates when it is convenientPoor - difficult to work withIntegrity*Excellent - consistently trustworthyGood - generally honest and trueAverage - honest, but may stretch the truthPoor - questionable at timesPersonable*Excellent - sharp, excellent first impressionGood - well-groomed, good first impressionAverage - gives an average first impressionPoor - neglects fine detail, sloppyCommunication*Excellent - articulate, communicates to all groups clearlyGood - communicates well with most groups of peopleAverage - gets the thought acrossPoor - difficultly in articulating thoughts, needs to be told what to doStress*Excellent - thinks well under pressureGood - able to make wise decisions under pressureAverage - reasonably calm under pressurePoor - abandons responsibility under pressureSociabilityPlease mark all which apply to the applicant.Sociability Gregarious, known by all Analytical, reflective, contemplative Withdrawn, a loner Confident, self-assured Blunt and up front Tentative, self-conscious Steady, consistent Amiable, loyal, devoted, friendly Timid and shy Brash and arrogant Hard to read Entertaining What do you consider special about the applicant?*How would you describe the applicant's relationship with God?*If my child were attending Lake Ann Camp this summer, the applicant as a support worker would be:*My first choiceA good choiceA concern to meA poor choiceI think a summer at Lake Ann Camp would be (choose the most appropriate answer)*Great for this applicantGreat for the campers who attendComments*Email* I prefer to discuss this on the phone. Please call me. Phone*Signature* Δ
