Forms For Reference Check
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1[Name of Your Church]
Forms for Reference Check
Applicant name: ____________________________________________
Reference name: ____________________________________________
Reference address: __________________________________________
Reference phone: ____________________________________________
1. What is your relationship to applicant?
2. How long have you know applicant?
3. How well do you know applicant?
4. Please describe the applicant.
5. Please describe the applicants ability to relate to
children/youth/vulnerable adults.
6. How would you access the applicant’s leadership abilities?
7. Would you be comfortable having the applicant as a volunteer working
with your child/youth/parents?
8. Do you know of any characteristics or actions that would negatively
affect the applicant’s ability to work with children/youth/vulnerable
adults? If so, please describe.
9. Do you have any knowledge that the applicant has ever been
convicted of a crime? If so, please describe.
10.
What else would you like us to know about the applicant
Reference inquiry completed by _________________________________
Name of staff/volunteer conducting interview
Date: _____________
Adapted from Safe Sanctuaries :Reducing the Risk of Abuse in the Church for Children, Youth and Adults
by Joy Thornberg Melton. This publication is available from Cokesbury. Please adapt as necessary for
your congregation.
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