RSCM Pacific NW: Adult Reference Form
Please fill out to the best of your ability & submit no later than June 1. Questions or technological difficulties? Email
Email *
Your name: *
Name of adult you are referring (first & last): *
How do you know this person? *
How long have you known this person? *
In what capacity have you seen this person interacting with children or youth? *
Would you trust this person to interact with children & youth? *
Is there anything you know about this individual that would make it inappropriate for him/her to be present with children & youth? *
If yes, please explain.
Do you have any knowledge that this person has been convicted of a criminal offense? *
If yes, please explain.
To your knowledge, has this person ever been found by a civil court to have caused significant harm to a child or young person under the age of 18, or has any civil court made any finding against him/her that any child or young person under the age of 18 was at risk of significant harm? *
If yes, please explain.
By checking below, I declare that all the information I have provided is true and complete to the best of my knowledge. I acknowledge that an affirmative response below consistutes my signature. *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy