Letter Of Reference Template

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LETTER OF REFERENCE #1
Name of Applicant: ______________________________________________________
(
Family Name)
Address:
____________________________________________________________
Your Name: ____________________________________________________________
Home phone: _______________ cell: _______________ email: __________________
Relationship to the Applicant:
1. How long have you known the applicant? _______________________________
2. What is your relationship to the applicant? _______________________________
__________________________________________________________________
__________________________________________________________________
3. Have you ever been in the applicant’s home? _____ yes
_____ no
Character Reference:
Young international students who may speak limited English and who are thousands of miles away from their
home and families are especially vulnerable. Are you aware of any conditions in the applicant’s home that may
impact the ability of the placement to succeed? Please check the boxes for any areas of concern. Additional
comments may be made below.
____ marital discord
____ alcohol or drug use
____ medical issues
____ severe depression
____ emotional disabilities
____ behavioural difficulties by children in the home
____ abuse (verbal, emotional, sexual)
Comments: (
use the back of this sheet for any additional comments)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature: __________________________

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