Name of the CHILD who listed you as a reference:
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First Name
Last Name
Name of the MENTOR completing this reference form:
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First Name
Last Name
Your email address:
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Relationship to applicant:
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How long have you known this applicant?
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Please rank the statements below from "I strongly disagree" to "I strongly agree."
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1. This child FOLLOWS INSTRUCTIONS. When an adult in a position of authority (teacher, coach, etc.) asks them to do something, they complete it as asked.
2. This child is NATURALLY CURIOUS. They seek ways to gather new information about the things they find interesting.
3. This child is COMFORTABLE IN THE WILDERNESS. Being in wild places without cars, phones, or other conveniences does not scare them.
4. This child is a LEADER. People look up to them as someone who takes action.
5. This child is TRUSTWORTHY. Even when no one is watching, they make good choices.
6. This child is INDEPENDENT. They can spend time away from their home and their family without becoming homesick.
7. This child is PHYSICALLY STRONG. They can use their body to accomplish tasks that require strength.
8. This child is SELF-CONFIDENT. They believe they can overcome any reasonable challenge that comes their way.
Additional explanation area (if needed).
Please use the box below to provide explanation(s) for any answers above you feel need some clarification. This is not required - and only necessary if you feel it is so.
QUESTION 1. The child you are acting as a reference for has just completed their first year on a youth soccer team. Their team is celebrating the end of their season with a sleepover party, but sleepovers have always been a challenge for this child. Even so, they decide to give this one a try because their best friend is also on the team. While driving to the party, their parents learn that the friend they were looking forward to being there has caught the flu and can’t make it. The applicant you are referring is mostly to:
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Please select ONLY ONE answer from the options below.
QUESTION 2. Tonight is the school carnival – a fun event that many people who live in your community look forward to. A teacher has volunteered this child's homeroom class to clean up the school’s front parking lot area during recess to help get ready for the event. The applicant you are referring is most likely to:
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Please select ONLY ONE answer from the options below.
QUESTION 3. This child has spent six long hours driving to a campsite in Utah, where they will spend the night before their river trip begins. As the vans get unloaded, a boy they didn't know before the trip realizes he left his duffle bag in the parking lot where the group met this morning. He has nothing more than what he is wearing. This applicant is most likely to:
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Please select ONLY ONE answer from the options below:
QUESTION 4. It is the first afternoon in the canyon. This applicant pairs up with a friend to set up their tent - something neither of them have ever done before. After finding the perfect spot, they give it a try. 30 minutes later everyone else has their tents set up properly, but theirs is slumping over and they seem to have an extra pole. This applicant is most likely to:
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Please select ONLY ONE answer from the options below.
QUESTION 5. This child just sat down in their camp chair for dinner, and noticed a giant bug with big pinchers crawling directly toward their foot. Their next move is most likely to be:
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Please select ONLY ONE answer from the options below:
QUESTION 6. While taking their tent down on the final morning of the trip, this applicant and their friend each grab a tent pole and begin a make-believe sword fight game. During the game, they accidentally break one of the poles by smacking it against a tree. This applicant would likely then:
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Please select ONLY ONE answer from the options below:
1. What makes this child stand out from their peers - in either a positive or a negative manner?
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2. If you were supervising an overnight field trip and this applicant was on your roster, what would make you most excited about having them involved? What would cause you the most concern?
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3. To your knowledge, does this applicant have any history of behavioral or emotional issues, substance abuse, or major rule infractions
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4. Is there anything else about this child you think it is important for GOALS to know?
