Adult Reference Form

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Please fill out to the best of your ability & submit. Questions or technological difficulties? Email rscmwashingtondc@gmail.com.

Your Name *

Name of Adult you are referring (First & Last) *

How do you know this person? *

How long have you known this person? *

In what capacity have you seen this person interacting with children or youth? *

Would you trust this person to interact with children & youth? *

Is there anything you know about this individual that would make it inappropriate for him/her to be present with children & youth? *

Yes

If yes, please explain.

Do you have any knowledge that this person has been convicted of a criminal offense? *

Yes

If yes, please explain.

To your knowledge, has this person ever been found by a civil court to have caused significant harm to a child or young person under the age of 18, or has any civil court made any finding against him/her that any child or young person under the age of 18 was at risk of significant harm? *

Yes

If yes, please explain.

By checking below, I declare that all the information I have provided is true and complete to the best of my knowledge. I acknowledge that an affirmative response below constitutes my signature. *

I affirm that all of the the above is true to the best of my knowledge.

Required

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