Character Reference Form Step 1 of 3 33% Applicant Name First Last Your InformationName* First Last Relationship to Applicant*How Long Have You Known the Applicant?*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Work Phone*Cell Phone*Best Time To Contact:8am-12n12n-5pmAfter 5pmEmail* Save and Continue Later Leadership & Social TraitsSociability or Friendliness* Avoided by Others Tolerated by Others Liked by Others Well-Liked by Others Sought by Others Responsiveness* Slow to Sense How Others Feel Reasonable Responsive Understanding and Thoughtful Responds with Unusual Insight and Consideration Intelligence* Learns and Thinks More Slowly Average Mental Ability Alert; Has a Good Mind Brilliant; Exceptional Capacity Conflict Management* Seems Passive-Aggressive Stuffs Frustration Explosive, Angry, Outbursts Effectively Works It Out Achievement* Does Only What is Assigned Starts but Does Not Finish Meets Average Expectations Resourceful and Effective Superior Creative Ability Teachability* Rigid, Argumentative Highly Opinionated Open-Minded Willing to Receive Instruction Eager to Receive Instruction Leadership* Makes No Effort to Lead Tries but Lacks Ability Has Some Good Leadership Promise Good Leadership Ability Unusual Ability to Lead Self-Image* Insecure Feels Inferior Self-Confident May be Prone to Boasting Modest, True Estimate of Self Emotional Adjustment* Yields to Urges or Cravings Tense, Fearful, Worried Easily Angered, Frustrated Downhearted, Blue, Depressed Maintains Balance, Self-Controlled Teamwork* Frequently Causes Friction Usually Cooperative Prefers to Work Alone Most Effective in Teamwork Save and Continue Later Personal TraitsCritical Spirit*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentArgumentative*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentDomineering Manner*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentProcrastinator*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentImpractical*--Not KnownFrequentlySometimesRarelyNever ApparentIrritable*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentEasily Discouraged*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentAnxious*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentMoody*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentCodependency*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentHomosexual Relationships*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentPunctual*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentHumble/Teachable*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentAdaptable*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentDependable*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentMature*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentAbility to Communicate*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentTake Initiative*--Not KnownVery ApparentFrequentlySometimesRarelyNever ApparentIf you wish, briefly and concretely describe specific instances which support or interpret your judgments above.Do you have any reservations concerning the personal integrity of the applicant?*YesNoI would like to talk further with someonePlease Select One:*---Applicant should be acceptedApplicant should NOT be acceptedApplicant should be discouraged from pursuing this programI recommend this applicant with reservations. Call me so I can explain.Would you like to add any further comment or insight?*YesNoAdd your additional thoughts here:I acknowledge that the judgments provided on this form were submitted by the individual named above and are complete and honest to the best of my knowledge. I understand that the information that I submit will be considered confidential, and will be kept secure and private. The Kanakuk Institute certifies that this information will be shared only with Institute staff members or related ministries, including Kanakuk Kamps, K-Life National, Kids Across America, and John Brown University.*I agree Save and Continue Later To complete the character reference form, please visit this page on your computer or tablet device.