Provider Reference Form

Applicant's Name:

Applicant's Residence

City/County/State

Please provide the following contact information:

YourName
Work Phone
Home Phone
E-mail

What is your relationship with this person?

How many years have you known this person?

How would you rate this person's dependability?PoorAverageGoodVery GoodExcellantSelect one

How would you rate this persons level of patience?PoorAverageGoodVery GoodExcellantSelect one

How would you rate his/her ability to relate to children?              PoorAverageGoodVery GoodExcellant Select One

How would you rate this person's ability to exercise good judgment? PoorAverageGoodVery GoodExcellant Select One

How would you rate this persons ability to handle stressful situations in an appropriate manner?PoorAverageGoodVery GoodExcellant Select One

What are his/her strongest qualities?

I know I can always count on him/her to...

Please list any additional comments about this persons character?

Did this person care for your children?Yes No  If No, skip to end and submit form.

 How long did this person care for your children:  From :To:

How many children did he/she care for during that time?

Ages of these children:

Do you believe that this person would provide a loving caring atmosphere forany child?  Disagree StronglyDisagreeNeutralAgreeAgree Strongly Select One

Would this person provide educational activities to a child in his/her care. NeverSeldomSometimesOftenAlways Select One

Would this person provide age appropriate activities and stimulation. NeverSeldomSometimesOftenAlways Select One

Would this person provide artistic and creative projects for a childin his/her care.  NeverSeldomSometimesOftenAlways Select One

This person would provide nutritional food choices for a child inhis/her care.  Not ApplicableNeverSeldomSometimesOftenAlways Select One

Would he/she provide an appropriately structured environment. (A good balance orfree play time and structured activities)  NeverSeldomSometimesOftenAlways Select One

This person provides plenty of positive feedback to a child in his/her care. NeverSeldomSometimesOftenAlways Select One

If circumstances permitted, would you use this person again?  Definitely NotProbably NotPossiblyProbably WouldDefinitely Would Select One

Would you recommend this person to others in need of a childcare provider. Definitely NotProbably NotPossiblyProbably WouldDefinitely Would Select One

If he/she is not currently caring for your children, why did you stop using him/her?

Did you ever have a problem with this person canceling without adequate notice? Did this happen often?

Do you consider this person a good role model for children? Why?

Describe how this person affected your child's emotional & educational development.

The thing my children enjoyed most about this person was...

Please list any additional comments regarding this person's ability to be a good childcare provider.