Staff Personal Reference Form - Gan Israel Day Camp of Merrick-Bellmore-Wantagh

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Name of Camp Applicant Receiving the Reference:*
First Name Last Name
Name of Person Giving the Reference:*
First Name Last Name
The above named individual has applied to become a camp counselor. Summer camp is provided here for children ages 1-8 years old, licensed by Nassau County Dept of Health. (S)he has given your name as a PERSONAL reference. Please complete the following reference form at your earliest convenience. )
1. How long have you known the applicant?*
2. What was the nature of your relationship?*
3. Discuss the experience required for this job:
3 How would you describe the applicant’s relationship with his/her friends/co-workers?*
4. Would you hire this person to work for you?*

YesNo
5. From your knowledge, how well does he/she relate to children?*
Areas of strength:*
Areas of weakness:*
Please rate the applicant on the following merits:
Character*
Dependability*
Leadership*
Creativity*
Sensitivity*
Tolerance*
Communication*
Enthusiasm*
Manners*
Cooperation*
Team Player*
Follows instructions*
Seeks advice when necessary*
Works independently (without constant supervision)*
Punctuality*
Uses vacation, personal & sick time responsibly
Overall performance of tasks
To your knowledge, has the applicant suffered any significant physical or nervous difficulties which would interfere with his/her work with children or staff?*
Would you want this person to be your child’s counselor/teacher? Why or why not?*
Reference Signature: *
Date:*

Month Day Year
Reference Printed Name: *
Company Name:

Reference Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Reference phone #: *

Area Code Phone Number
I can be called between *
Should be Empty:

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