RSCM Washington DC Residency Adult Reference Form

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In order to assure the safety of all children and adults participating in the 2025 RSCM Washington DC Summer Residency, we require all adult participants to have two people complete references on their behalf. Please complete the information below to the best of your ability. Please note that members of your own family cannot serve as one of your references.

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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