Reference Form

Your name has been given to us as a reference for a volunteer who has applied to be a mentor in our program. Please take a few minutes to answer some questions about him/her, which will be held in absolute confidence; it will not be shared or accessible to him/her. Please contact us at (919) 663-0116 if you have any questions or concerns. Thank you.

Mentor Applicant Name(Required)

First Last

Your Name(Required)

First Last

Date(Required)

How long, and in what capacity, have you known the applicant?(Required)

How does the applicant relate to people in general?(Required)

List 5 characteristics to describe the applicant? (ie. Sincere, shallow)(Required)

Do you feel that the applicant would be a good mentor and role model to a child? Why or why not?(Required)

Please give an example of why you think the applicant relates well to children and young people?(Required)

Does the applicant usually keep his/her commitments and/or appointments?(Required)

Yes

Unsure

To your knowledge, has the applicant ever been convicted of a crime other than minor traffic offenses?(Required)

Yes

Do you know of any problems or issues that would affect the applicant’s ability to work with a child? (ie. Work schedule, family commitment, etc.,)(Required)

Why or why not would you feel comfortable allowing the applicant to spend time alone with your child?(Required)

Do you have any additional comments about the applicant?

Signature (Please type out your full name)(Required)

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Reference Form

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