GVRC Staff Reference Form - Genesee Valley Rotary Camp

Applicant Information

Applicant Name*

First Last

Date

Note to person completing this form: Genesee Valley Rotary Camp is a one week residential summer camp for children and young adults (ages 8-21) with disabilities. The applicant named above has submitted your name as a reference. In order for us to make a better determination of his/her ability to perform as a staff member at our camp, we need you to complete this form as accurately as possible based on your personal and/or professional knowledge of the applicant.
Thank you for your cooperation.

How long have you know the applicant?*

In what capacity have you known him/her?*

How would you rate the applicant on these qualities?

Responsibility*

excellent
good
fair
poor

Initiative*

excellent
good
fair
poor

Creativity*

excellent
good
fair
poor

Leadership*

excellent
good
fair
poor

Maturity*

excellent
good
fair
poor

Work Ethic*

excellent
good
fair
poor

Energy/Enthusiasm*

excellent
good
fair
poor

Common Sense*

excellent
good
fair
poor

In your opinion, is the applicant responsible enough to entrust him/her with (disabled) children?*

Our camp is sponsored by many local Rotary Clubs. The Rotary Club motto is “Service above self”. Would this person be able to put the campers’ needs before his/her own?*

Your Information

Your Name*

First Last

Position*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Signature*

Date*

GVRC Applicant Reference Form

Applicant Information

How would you rate the applicant on these qualities?

Your Information