Family Reference Reference Name* Reference for...* How long have you known the applicant and in what capacity? Did you know the application was applying to be a mentor? Yes No If so, what was your reaction? What personal strengths do you feel the applicant has to offer?Based on your knowledge of the applicant, to whom would he/she turn to for support or gudiance? Can you tell me about the applicant's community involvement and personal interests?Can the applicant be counted on to follow through on the commitments he/she undertakes? Yes No When have you witnessed the applicant interacting with children? How does the applicant interact with or relate to children?Have you ever known the applicant to be inappropriate (emotionally, physically, verbally, sexually) with either adults or children? Yes No If so, please explain: To your knowledge, has the applicant ever had any trouble following the rules? Yes No If so, what kind of rules? Is there anything that you are aware of that may interfere with the applicant's ability to mentor or that would cause their commitment to our organization to come to an end? Yes No Has the applicant experienced an addiction, health or emotional concern that may impact his/her ability to participate actively in a match? Yes No Would anything need to change in the applicant's home environment to be suitable for a child's visit? Yes No Would you allow the applicant to develop a one-to-one relationship with your child or a child you care about? Yes No If not, why not? Would you recommend the applicant as a mentor for a child or youth? Yes No Is there anything else you would like to add that would aid us in our decision?CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
