First United Methodist Church - Lancaster Pa

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Please complete this reference by checking the category which mnost accurately corresponds to your impressions of the applicant.

*Applicant's Name:   

*How long have you known this person?  Select OneLess than 1 year1 - 3 years3+ years

*Under what circumstance have you been acquainted?  Select OneWorkSchoolChurchOther

     If other, please explain: 

*Sense of responsibility:  Select OneVery dependableUsually dependableUndependable

*Cooperation:  Select OneWorks well with otherCooperative only under pressureNot cooperative

*Emotional stability:  Select OneStable/Good self-worthMoodyEasily disturbedOther

     If other, please explain: 

By their daily example, would this person serve as a positive Christian role model for our children/youth?  Select OneYesNoUnsure

*To the best of your knowledge, does this person…

     abuse alcohol:  Select OneYesNoUnsure

     use illegal drugs: Select OneYesNoUnsure     

          If yes, please explain: 

*To the best of your knowledge, has this person ever cause any Child Abuse of any kind (i.e. verbal, sexual or physical)?  Select OneYesNoUnsure

     If yes, please explain: 

*Would you feel comfortable if your child was under the direct supervision of this person? Select OneYesNoUnsure

     If no, please explain: 

Please elaborate on or share additional background areas in which this person may need special assistance or guidance?

*Do you recommend this person as a volunteer to work with children/youth?  Select OneWithout reservationWith minor reservationWould not recommend

Additional Comments:

*Your Name: 

*Date:    (example: 11/27/2009)

*Phone Number:   (example: 717-555-1212)

First United Methodist Church accepts applicants of any race, color and national or ethnic origin.

Thank you very much!