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Reference Form (Confidential)

Form D

Alexandria Covenant Church (To be filled out by applicant) Name of Applicant/Candidate:________________________________________________ □has waived any right to see this reference □has released you from liability for your response □has not waived any right to see your reference □has not released you from liability for your response Former Pastor’s Name:___________________________________________________ Former Church’s Name and Address_______________________________________ _______________________________________________________________________ Telephone: ( )______________________________________________________ (If you do not have a former pastor, please give another reference) Name: _________________________________________________________________ Relationship_____________________________________________________________ Telephone: ( )____________Address:____________________________________ Signature of Applicant:___________________________________________________ Questions: (To be filled out by ECC Pastor or Children’s Ministry Coordinator)

1. In what capacity do you know the applicant? (Position Title, paid vs. unpaid, dates) ______________________________________________________________________ 2. Are you aware of any facts demonstrating that the candidate’s volunteer service for children or youth ministry should be restricted or not considered? □ yes □ no If yes, please explain:_____________________________________________________ ______________________________________________________________________ 3. Based on your knowledge of the applicant/candidate, which of the following best reflects your evaluation of him/her? □ Highly recommend □ Recommend □ Neutral □ Do not recommend □ Insufficient knowledge to form an opinion 4.

Is there anyone else I should talk to about the applicant’s suitability to work with children/youth:_____________________________________________________________ 5. Do you have any additional comments concerning the suitability of this applicant to work in our church____________________________________________________________ This form accurately reflects the contents of a telephone conversation I had with the reference on the date indicated. _________________________________________________________________________

____ C.E. Board contacted and volunteer’s name entered on the master list of screened volunteers.


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