Contact

General Information
info@phoc.org
4654 Pleasant Hill Rd.
Perrysville, OH 44864
419 938-3715

Confidential Reference Form
Pleasant Hill Outdoor Center

To Whom it May Concern;
Thank you for taking time to complete this reference on behalf of the applicant. I'm sure you'll understand that because we work with children your honest opinion is most helpful. Please be sure to enter the correct applicant name in the space provided to avoid confusion. We will almost certainly contact you briefly by phone to verify the authenticity of this reference. Thank you.

Applicant's Name: (please be careful to enter accurately)

First

Last

What is your relationship to the applicant? (check all that apply)

Pastor/ Minister

Teacher

Employer

Friend

Other

How Well do you know the applicant? (check all that apply)

Very Well

Employee

Somewhat Well

Business

Acquaintance

Classroom

Please check the description that best fits the applicant. If in doubt, check more than one. Leave a question blank if you do not feel you do not know.

Fulfils Obligations

Takes obligations to others seriously

Usual fulfils obligations

Little respect for fulfilling obligations

Flexibility

Naturally Flexible

Will be flexible when asked, but can go with the flow

Prefers their own way and lets others know it

Emotional Balance

Very well balanced

Has their moments

Often unstable

Response to Authority

Accepts authority well

Generally responds to authority

Know to struggle with authority

Christian Maturity

Mature beyond their age

Maturity consistent with age

Lacks maturity for age

Relationship with Others

Sought by others

Liked by others

Tolerated by others

Leadership Ability

Naturally followed by others

Can lead if given directions

Fits best in a group when following

Temper Control

rarely loses composure

Generally even tempered

Struggles with temper control

Tact

Tactful even in tough situations

Generally tactful

Lacking in tact

Does the applicant appear to have a growing and sincere relationship with God?

Yes/ probably

No/ I doubt it

Insufficient information to comment

Do you have any knowledge of this person ever being convicted of a crime, other than a minor traffic offense including any sexual offence crimes?

Yes

No

If yes, please explain:

Is there any reason you are aware of this applicant should NOT be permitted to work with children in a residential camp setting?

Yes

No

If yes, please explain:

Would you expect the applicant's work to be:

Superior

Good

Fair

Poor

I verify my identity by checking this box to the person named here.

Your Name

Date

Your Phone*

( )

Your E-Mail*

*We may contact you briefly by phone to verify the authenticity of this reference.