(To be filled out by applicant) Name of Applicant/Candidate:________________________________________________ □has waived any right to see this reference □has released you from liability for your response □has not waived any right to see your reference □has not released you from liability for your response Former Pastor’s Name:___________________________________________________ Former Church’s Name and Address_______________________________________ _______________________________________________________________________ Telephone: ( )______________________________________________________ (If you do not have a former pastor, please give another reference) Name: _________________________________________________________________ Relationship_____________________________________________________________ Telephone: ( )____________Address:____________________________________ Signature of Applicant:___________________________________________________

Reference Form (Confidential) Form D Alexandria Covenant Church

Questions: (To be filled out by ECC Pastor or Children’s Ministry Coordinator) 1. In what capacity do you know the applicant? (Position Title, paid vs. unpaid, dates) ______________________________________________________________________ 2. Are you aware of any facts demonstrating that the candidate’s volunteer service for chil-

dren or youth ministry should be restricted or not considered? □ yes □ no If yes, please explain:_____________________________________________________

______________________________________________________________________

3. Based on your knowledge of the applicant/candidate, which of the following best re-flects your evaluation of him/her? □ Highly recommend □ Recommend □ Neutral □ Do not recommend □ Insufficient knowledge to form an opinion

4. Is there anyone else I should talk to about the applicant’s suitability to work with chil-dren/youth:_____________________________________________________________

5. Do you have any additional comments concerning the suitability of this applicant to work in our church____________________________________________________________ This form accurately reflects the contents of a telephone conversation I had with the refer-ence on the date indicated. _________________________________________________________________________

____ C.E. Board contacted and volunteer’s name entered on the master list of screened volunteers.

6-29-10

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