CONFIDENTIAL REFERENCE FORM

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Camp Kydnie is a camp designed specifically for children with kidney disease, who are at least 6 years of age. The goal of Camp Kydnie is to provide a normal camping experience, allowing for health and physical limitations, and with an emphasis on positive self-image, independence and self-assurance.

The goal of the Counselor-In-Training (CIT) program is to provide young adults with the opportunity to learn the leadership skills that are necessary for them to act as role models for children younger than themselves. CITs will be assigned to a specific group for the week, and through hands-on experience, will have the opportunity to interact with campers ages 6-18, counselors and staff in the operation of the week long summer camp experience. Due to extensive interpersonal connection, CITs should be friendly, approachable and of mature level.

Name of Applicant for which you are providing a reference: *

How long have you known the applicant? *

In what capacity have you known the applicant?

Reference Type

All applicants are required to provide two references; one from a current or past educator and one from a non-relative (i.e.: coach, community leader, etc.)

Please indicate which type of reference you are providing: *

Evaluating the applicant

Please evaluate the applicant in each of the following areas:

Demonstrates age-appropriate maturity *

Demonstrates follow-through *

Is dependable and reliable *

Possesses a strong record of attendance and being on time *

Is accepting of diverse populations *

Willingly takes the role of a leader or follower as needed *

Possesses a positive attitude *

Demonstrates self-motivation *

Is creative and innovative *

What is your overall recommendation? *

Additional Information:

Please provide your contact information to include your name, address, telephone number and email address. *

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