Local Church Certification

General Reference Form

*This reference must be completed by a person who is not related to the applicant.

The person providing the reference must have know the applicant for at least two years.
The person providing the reference must be able to assess the applicant’s ability to supervise children and youth.

All information in the Safe & Sacred process is confidential and the applicant has waived the right to see or review records in his/her file. 

Applicant Name *
Applicant Name
How long have you known this person *
Have you actually witnessed this person's ability to relate to chilren and/or youth? *
This person uses appropriate verbal and visual language with children, youth and vulnerable adults. *
e.g. does not use sexually explicit words, does not tell inappropriate jokes, does not speak in ways that might suggest more intimate relationships, does not show sexually graphic or suggestive photo or electronic images
This person uses appropriate forms of physical touch and other tend to feel comfortable with this person. *
e.g. does not initiate prolonged or suggestive hugs, makes physical contact with others that is consistent with all persons rather than more intimate or prolonged contact with specific individuals, refrains from touching parts of the body that could cause the other person to feel uncomfortable
This person refrains from all forms of enticement for sexual favors including the promise of money or gifts. *
e.g. does not promise rewards in return for closer personal relationships, does not foster relationships that maintain secrets or overly private encounters
This person refrains from activities that cause children, youth, or vulnerable adults to feel uncomfortable. *
e.g. does not invade the other person’s space of comfort, does not participate in prolonged gazing or inappropriate grabbing or tickling, does not encourage relationships between others that makes them feel awkward or uncomfortable
This person, to my knowledge, is trustworthy and responsible. *
This person is able to set and maintain appropriate boundaries with children and youth, being the adult in all situations. *
This person is able to be in charge of a group of youth or children, giving direction, providing supervision and disciplining appropriately. *
If you were in our position, would you affirm this person as a volunteer with children, youth and/or vulnerable adults? *
Reference Name *
Reference Name
(Your Name)
Phone *
Today's Date *
Today's Date