Counselor Reference

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Counselor Reference

Counselors are required to provide three references. All people filling out references must be 21 years or older, a non-family member, and at least one reference must be from the pastor of the church they are attending.

* Indicates required field

Name of Prospective Counselor *

First

Last

How long have you known this person? *

In what capacity do you know this person? *

Has this person ever been convicted of a crime of which you are aware? *

YES NO

If you answered YES to the above question, please explain: *

Is this person active in his/her local church? *

YES NO

Does this person seem mature in handling discipline and authority? *

YES NO

If your own child was placed in this person's cabin, would you feel comfortable? *

YES NO

Have you observed this person interacting with children or youth? *

YES NO

Do you have any comments or concerns about how this person interacts with children or youth? *

To the best of your knowledge, how long has this person been employed at their current place of employment? *

Would you recommend this person as a counselor without any reservations? *

YES NO

Your Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Submit

Counselor Reference

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