2019 CITs - Teacher Reference Form

Dear Teacher,

You have been listed as a current teacher of the individual mentioned, who has expressed an interest in working with children or youth as a Counselor-in-Training during the Summer Camp Ministry of Camp Dixie. The Counselor-in-Training program prepares students to serve in a future position as counselor at Camp Dixie. They attend a weekend training session, complete assignments, and, if chosen after training, will be given the opportunity to serve this summer for one or more weeks alongside an experienced camp counselor. In order for us to properly evaluate the qualifications of this applicant, we ask that you complete this form with your honest opinions and impressions of the applicant.

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* 1. What is the name of the applicant you are recommending?

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* 2. What is your name?

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* 3. What is the name of the school at which you work?

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* 4. What class do you teach?

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* 5. How long have you known the applicant you are recommending?

Less than 6 months

6 months - 1 year

1-2 years

3-4 years

4+ years

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* 6. Do you have any reason to believe the applicant would be unreliable, dishonest, or of questionable character?

Yes (please explain)

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* 7. Based on your interactions with this applicant, does he/she show respect for authority ?

Yes

No (please explain)

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* 8. Do you have any concern with the applicant working with children/youth?

Yes (please explain)

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* 9. Are you aware of anything in the applicant's background, personality, or behavior that could pose a threat to children/youth?

Yes (please explain)

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* 10. Check 3-5 words that BEST describe the applicant

Teachable

Tolerant

Domineering

Enthusiastic

Wise

Fearful

Critical

Flexible

Dependable

Motivated

Anxious

Prejudiced

Patient

Easily Discouraged

Easily Offended

Understanding

Servant-Hearted

Humorous

Perfectionist

Disciplined

Moody

Assertive

Childlike

Considerate

Friendly

Immature

Lazy

Quick-tempered

Responsible

Quiet

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* 11. On a scale of 1-5 (1 being weak and 5 being strong), please rate the applicant in the following areas:

	1	2	3	4	5
Respect for Authority	Respect for Authority 1	Respect for Authority 2	Respect for Authority 3	Respect for Authority 4	Respect for Authority 5
Leadership Ability	Leadership Ability 1	Leadership Ability 2	Leadership Ability 3	Leadership Ability 4	Leadership Ability 5
Ability to Take Directions & Follow Through	Ability to Take Directions & Follow Through 1	Ability to Take Directions & Follow Through 2	Ability to Take Directions & Follow Through 3	Ability to Take Directions & Follow Through 4	Ability to Take Directions & Follow Through 5
Ability to Take Initiative without Directions	Ability to Take Initiative without Directions 1	Ability to Take Initiative without Directions 2	Ability to Take Initiative without Directions 3	Ability to Take Initiative without Directions 4	Ability to Take Initiative without Directions 5
Concern for others	Concern for others 1	Concern for others 2	Concern for others 3	Concern for others 4	Concern for others 5
Participation in Activities	Participation in Activities 1	Participation in Activities 2	Participation in Activities 3	Participation in Activities 4	Participation in Activities 5
Communication Skills	Communication Skills 1	Communication Skills 2	Communication Skills 3	Communication Skills 4	Communication Skills 5
Teachability	Teachability 1	Teachability 2	Teachability 3	Teachability 4	Teachability 5
Strong Moral Character	Strong Moral Character 1	Strong Moral Character 2	Strong Moral Character 3	Strong Moral Character 4	Strong Moral Character 5
Ability to Work with Others	Ability to Work with Others 1	Ability to Work with Others 2	Ability to Work with Others 3	Ability to Work with Others 4	Ability to Work with Others 5
Works to the best of his/her ability	Works to the best of his/her ability 1	Works to the best of his/her ability 2	Works to the best of his/her ability 3	Works to the best of his/her ability 4	Works to the best of his/her ability 5

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* 12. Anything else you'd like to tell us concerning this applicant?

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* 13. In order to verify this reference, we will need to contact you upon receiving this information. Please provide an email address to which we can send a confirmation email?This reference will not be filed until we have received your email confirmation.