Reference Form Reference Date* MM slash DD slash YYYY Name* First Last Reference for:* Information based upon:* Personal acquaintance Co-worker Worked under my supervision Relationship* Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*How long have you known this individual and in what capacity?*Do you believe they would be a good example around children?* Yes No N/A If this person has worked for you in the past, would you rehire?* Yes No N/A Have you seen them interact with children? If so, please comment on that interaction.*How does this person relate to others?*What do you consider to be their strengths?*What do you consider to be their weaknesses?*Statement of Agreement* To the best of my knowledge, the information I have provided in this reference form is true and correct.