Dear Parent or Small Group leader,

The person whose name is given on the attached reference questionnaire is seeking to
participate in a summer trip with Escape22, the High School ministry of Cornerstone
Church. We are grateful for your assistance in helping evaluate the applicant’s potential
for service. Please write your name and address in the space provided at the top of the
form and include your signature and the date at the end of the form.

Since it is our purpose to secure an understanding of the applicant’s personality, please

be completely frank. Feel free to offer pertinent facts and judgments not covered by the
questions and which exceed the space limitations where you think it is necessary. Please
include both favorable and unfavorable comments that will enable us to determine the
applicant’s qualifications for this trip. Thank you for your help.

Please return this reference form to the Cornerstone office ASAP and at least by the
February 17th deadline. You can mail it to us at 56829 US Hwy 30, Ames, IA 50010, fax it
to us at 515.232.3291 or email it to us at cmcline@gmail.com.

Please be assured that your reply will be kept confidential.

Thank You,

Cody Cline
Escape22 Director
Cornerstone Church
 Please mail, fax or email to:
Escape22
56829 US Hwy 30, Ames, IA 50010 ▪ 515.232.5488 (phone) ▪ 515.232.3291 (fax) ▪ cmcline@gmail.com

Confidential Reference on: _________________________________________________________

(Applicant’s name)
Please be as objective as possible in your evaluation of this applicant. This reference is most valuable to us when completed as honestly as
possible by someone who knows the applicant well. In student trips aimed at sharing the gospel with both words and actions it is essential
that our students are exactly who they claim to be. Please keep this in mind as you fill out this evaluation. Thanks

Your Name: _____________________________________________________________________

Your Address:____________________________________________________________________

In what capacity have you known the applicant? Parent Small Group Leader Friend Other ___________

How long have you known the applicant? _________ years

How well would you say you know the applicant? Surface Personal Very Personal

What communication have you had with the applicant in the past six months? None Surface Personal Very
Personal

Following are 6 short answer questions. It would be a great help to us if you would briefly explain
your answers.
1. If you were going on this trip, would you want this person on your team?
Yes Yes, with hesitations No
Please briefly explain:

2. Have you observed the applicant relating to members of the opposite sex? How would you describe what
you observed? Any concerns that would warrant our attention?

3. How does the applicant interact with other people? (friendly, distant, warm, fun, abrasive, awkward, good
social skills? Does he or she joke at other people's expense? etc.) Please explain.

4. Please describe two things about the applicant that you think will be a blessing to his or her team/team
leader.

5. Please describe two things about the applicant that you think could be difficult for the team/team leader
to appreciate or adjust to.

6. How would you describe the applicant’s current spiritual growth and relationship with God?

If we have any questions concerning your reference on this applicant, may we please call you? Daytime phone:
_________________

Signature: ______________________________________________________ Date: _____________________________