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Dasche New Family Reference Check Form

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Thank you for taking the time to complete this reference form! One form must be filled out per child in the family. 
1. *

Your Name:
2. *

Your Email:
3. *

Phone Number: 
4. *

Students First and Last Name that you are submitting this reference for:
5. *

How long have you known the student?
6. *

In what context have you known this student?

 (1 required)
Friend of Family Sunday School Teacher
Youth Pastor Pastor
Teacher Relative
Neighbor Babysitter
Other
7. 

If you chose "Other" please describe:
8. *

Please name 2 positive character traist that you appreciate and have observed in this student:

 (1 required)
Encourager of Others Studious
Servant's Heart Mature
Hard Working Organized
Selfless Responsible
Kind Leadership
Optimistic Trustworthy
Patient Compassionate
Other
9. 

If you chose "Other" please describe:
10. *

Name 1 or more areas below where this student may need to work on his/her character development as he/she continue to mature:

 (1 required)
Critical of Others Immature
Temperamental Irresponsible
Lazy Selfish
Moody Impulsive
Disorganized Dishonest
Other
11. 

If you chose "Other" please describe:
12. *

In your opinion, would you say this student is:

 (1 required)
Easily Influenced by peers (a follower) Passively stands on their own beliefs
Actively influences peers (a leader)
13. *

Based on what you know, would you feel comfortable having your own children spend extended time with this student?

 (1 required)
Yes No
14. 

If you chose "No" please explain further:
15. *

On a scale of 1-10, with 10 being the best, how would you rate the overall Christian character of this student in comparison to others in their age group?
16. *

The Scholastic Co-op involves the role of the parent as the primary homeschool teacher. On a scale of 1-10 with 10 being the best, how would you rate the relationship between the student and his/her parents in comparison to other families you know?
17. *

On a scale of 1-10, with 10 being the best in comparison to othe families you know, would you say that this family is easy to get along with, easy to work with, and is cooperative in a group setting with other families (ie, church, athletics, group functions, ect)?
18. 

Is there any additional information about this student or his/her family that you feel would be helpful regarding their admission to the Scholastic Co-op? (If no, type N/A)
19. *

By typing your name below, you agree that this constitues your electronic signature.
20. *

Date:
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