Reference Form

Name of camper you are recommending*

First Last

Your Name*

First Last

Your Phone Number*

How long have you known the applicant and in what primary context?*

Motivation and Maturity

How would you rate this teens social maturity?*

1 - Readily views program goals above personal comfort. Happy to help other participants without being asked. Not judgemental of others.
2 - Well liked and makes friends easily. Primarily focused on him/herself and/or close friends.
3 - Does not always react appropriately to the mood of the program or sensitivity of others. Has trouble making and/or retaining friends. With staff assistance, can integrate into the group.
4 - Routinely misses social cues. Inability to consider needs or perspectives of others. Requires constant help and supervision.

How would you rate this teen's emotional maturity?*

1 - Mature beyond his/her years. Has the ability to express and regulate his/her emotions.
2 - Responds to emotional situations appropriately for his/her age.
3 - Emotionally immature.
4 - Expresses emotions inappropriately.
I don't know

How would you rate this teen's physical capabilities?*

1 - The teen at the front of the hike.
2 - The teen who participates happily but might need some motivation.
3 - The teen who joins activities last. Might not enjoy it, but will persevere.
4 - The teens who will not be able to complete the activity in time with the group/physically unfit/overly negative.
I'm not sure.

How would you rate this teen's motivation?

1 - Actively participates in all programs and engaged in discussions.
2 - Attends programming willingly. Engages sporadically. Does not distract or disrupt regardless of who is running the program.
3 - Easily influenced by the environment, both for positive and negative outcomes (Example: Peers/Relationship with staff running program)
4 - Actively disruptive and avoids attending programming.

To your knowledge, has the applicant been involved in any incident involving drugs, alcohol, smoking or inappropriate behavior?*

To your knowledge, has the applicant been expelled from any school, camp or any other program?*

Do you think this teen will positively add to the Camp Kesher experience - will it be beneficial for them as well as for the other teens involved?*

Do you recommend that this teen should attend Camp Kesher?

Is there any additional information you would like us to be aware of?