Name of the CHILD who listed you as a reference:
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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Please briefly describe your relationship to the applicant:
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How long have you known this applicant?
Please rank the statements below from "I strongly disagree" to "I strongly agree."
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This section should be completed by the child applying to participate, with as little parental assistance / influence as possible.
1. This child FOLLOWS INSTRUCTIONS. When an adult in a position of authority (teacher, coach, etc.) asks them to do something, it is completed as asked.
2. This child is NATURALLY CURIOUS. They seek ways to gather new information about things they find interesting.
3. This child is COMFORTABLE IN THE WILDERNESS. Being in wild places without cars, phones, or other conveniences does not inhibit them.
4. This child is KIND. They enjoy helping others without expecting to get anything in return.
5. This child SEEKS OPPORTUNITIES FOR PERSONAL GROWTH. They work to improve their mental health as much as they do their my physical health.
6. This child is a LEADER. People look up to them as someone who takes action.
7. This child is OUTGOING. They can socialize and work well with just about anyone.
8. This child is TRUSTWORTHY. Even when no one is watching, they make good choices.
9. This child has EMPATHY. They can relate to others in a nonjudgmental and supportive manner even if they don't share their life experiences or problems.
10. This child HAS "GRIT" - when faced with a difficult challenge, they get motivated to dig deep and succeed rather than get frustrated and give up.
11. This child is GENUINE. They demonstrate sincerity and authenticity through actions and words without hypocrisy.
12. This child is PHYSICALLY STRONG. They can use their body to accomplish tasks that require strength.
13. This child USES THEIR VOICE. They advocate for what they believe is right, and speak up when it is necessary - even if it might not be "popular" or "easy."
14. This child is SELF-CONFIDENT. They believe they can overcome any reasonable challenge that comes their way.
QUESTION 1. This applicant and their best friend are at the first pep assembly of their freshman year in high school. They are seated in the back of the auditorium, not sure what to expect – when the principal pulls their name out of a hat to come up on stage and lead the entire student body in singing the school’s fight song. They are most likely to:
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Please select ONLY ONE answer from the options below.
QUESTION 2. The group has spent six long hours driving to their first campsite in Utah, where they will spend the night before their river trip begins. As the vans get unloaded, a boy this applicant 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 3. On the second day of their river expedition, this applicant woke up to the sound of drizzle outside their tent and it hasn’t stopped raining all day. When the group finally arrive at their campsite for the night, the mosquitoes are awful. This applicant is most likely to:
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Please select ONLY ONE answer from the options below.
QUESTION 4. This applicant is on an international GOALS expedition in Chile, and they are starving. There is a neighborhood market/grocery store just down the street from their hostel, but they speak almost no Spanish. The city they are staying in is safe, and going into the market alone is not dangerous. Therefore, one of the adult leaders gives them 10,000 Chilean pesos (about $15), and encourages them to be brave, and go get a snack. This applicant is most likely to:
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Please select ONLY ONE answer from the options below:
QUESTION 5. Yesterday, this applicant was very impressed watching their friend row one of the big, heavy gear boats - so today they decide to give it a try. Shortly after the guide gives them the oars, they seem to be getting the hang of it. Just then, a very strong headwind comes up and begins blowing their raft upstream. This child is most likely to:
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Please select ONLY ONE answer from the options below:
QUESTION 6. This child is on a river expedition with one of their closest friends - who has been asking for three straight days if they will be their partner in a "double ducky" (2-person inflatable kayak). Today is the day their group will paddle through “Wire Fence” – one of the biggest rapids of their trip. This child thinks they are finally ready to go for it, and spends the morning practicing through some smaller rapids as their friend's ducky partner. The friend who encouraged them is so excited – even pointing out to the entire group how proud they are of this child's bravery. When the group hikes to scout Wire Fence rapid, however, this applicant decides it looks like too much - and their gut tells them paddling it in an inflatable kayak is not something they want to do. They are most likely to:
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Please select ONLY ONE answer from the options below.
QUESTION 7. While taking their tent down on the final morning of the trip, this applicant and their tent mate each grab a tent pole and begin a make-believe sword fight game. During the game, they accidently break one of the poles by smacking it against a tree. This child is most likely to quickly:
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Please select ONLY ONE answer from the options below.
QUESTION 8. On the last night of their GOALS international expedition in Peru, the community is celebrating a local holiday in the town park that is only a few blocks away from the hostel where the group is staying. Several elders from the village are playing music while a lamb is cooking all afternoon over a large barbeque pit. The group's adult leaders announce with excitement that everyone has been invited to participate in this community celebration and experience the traditions it is centered around. This child is most likely to:
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Please select ONLY ONE answer from the options below.
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.
1. What makes this applicant 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 yabout this child you think is important for GOALS to know?
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Date of Reference Submission:
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