Clergy and Educator Abuse Survivors Empowered!	Prevention

Reference Contact Form

(for all workers with children and youth)

_______________________________________________________________________
(Name and Address of Local Church)

_______________________________________________________________________

Name of Volunteer __________________________  Request Date ___________

Reference Name ______________________   Telephone (___) ___________

Address _______________________________________________

The _______________________ Seventh-day Adventist Church is committed to providing a safe environment where children and youth may learn to love and follow Jesus Christ. The person named above has volunteered to work with children and/or youth and has given your name as a reference along with a release statement which appears on the reverse side of this page. We ask for your comments and opinions regarding the suitability of this person as a worker with children or youth. Please return this form in the enclosed self-addressed envelope. You may also call the pastor at ______________________

Thank you for your prompt attention to this request.

 ______________________________________________________________________

What is your relationship with the named volunteer?

How long have you known this person? _____

Describe what kind of contact this person has had with children or youth. (i.e. parent, youth worker, teacher, etc.)

Have you been able to make direct observations of this person actually working with children or youth?

__Yes      __No

If yes, please summarize briefly your observations.

Do you know of any reason why this person would NOT be suitable for work with children or youth?

__Yes    __No

If YES, please explain and include facts and names of other persons who can confirm these facts.

Do you have any reservations about recommending this person for work with children and youth and prefer not to provide further information?

__Yes   __No

If no, please state your recommendation.

Signature_______________________   Date___________

(Photocopy of release statement below)

................................................................................................................................

For office use only

• Phone contact date by ______________

• Written reference received on ___________