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Youth Delegate Reference Form

Childrens International Summer Villages, Inc.
__________________________ who is a youth applicant for a CI ! program. "first and last name# The youth is applying for$ "Chec% one# !illage "&onth'long peace education residence camp for (( year olds# ummer Camp "Three'wee% peace education residence camp for ()'(* year olds# Interchange "+eace education e,change program for (2'(* year olds# eminar Camp "+eace education camp program for (-'(. year olds/ (.0# Youth &eeting "+eace education e,change program for (2'()/ (1'(*/ (2'(./ (30 year olds# The youth applicant will 4e representing the 5nited tates and his6her own state and region in an international setting. The local Chapter of CI ! re7uests your help in identifying an applicant who e,hi4its leadership 7ualities and can represent his6her own culture successfully in that setting. +lease complete the form and return it 4y mail to the Chapter contact person identified 4elow. This form is due 4y$ ____________________. +lease return form to$ Chapter contact person phone num4er$ ________________________ 8ame of adult completing this reference form$ ____________________________________________________________ 9ccupation$ ____________________________________________:ome +hone$ _______________________________ Capacity in which you %now the youth applicant$ __________________________________________________________ If you are the child;s current teacher/ please include your school name and phone num4er$ __________________________ <ength of time you ha=e %nown the child:


+lease chec% the traits you consider to 4e characteristic of this applicant. Then circle the fi=e ad>ecti=es you feel descri4e the applicant;s greatest strengths. Feel free to ela4orate on any trait or any concern that would 4e helpful for the purposes of selecting this child for a CI ! program. ?eep in mind that we are loo%ing for children who complement each other when forming program delegations. There is no set profile of a @typicalA or @idealA youth delegate. mature independent responsi4le e,pressi=e accepting discerning shows initiati=e optimistic pessimistic responsi=e cooperati=e cautious curious attenti=e practical helpful participates needs coa,ing caring spontaneous reticent open'minded respects adults respects peers follower leader team player fair'minded organiBed dependent creati=e 7uiet secure =i=acious sensiti=e forgetful introspecti=e friendly articulate accepted unusual sincere healthy confident tolerant compromiser intense mild'mannered patient hurried studious moti=ated disrespectful athletic artistic outgoing inward intolerant fle,i4le follows direction fun conscientious shares tal%ati=e ad=enturous ___________ 5se this space to ela4orate on any of these traits circled on the pre=ious page or to e,press any concerns$

Do you %now of any special talents or e,periences that would help this applicant contri4ute to an international programC ________________________________________________________________________________ To the 4est of your %nowledge/ does this applicant ha=e any emotional or 4eha=ioral characteristics that would interfere with his6her successful completion of a CI ! programC ______________________________________ Deha=iors that are 89T accepta4le in any CI ! program include$ illegal acts/ alcohol6drug a4use/ dishonesty/ pre>udice or intolerance/ =iolence or lac% of self'control/ se,ual contact/ =er4al a4use of others/ and ina4ility to handle a reasona4le amount of stress. If @yesA/ please e,plain in the space 4elow or call the Chapter contact person at the phone num4er listed on the front of this form.

The information pro=ided a4o=e has 4een thoughtfully and honestly gi=en/ 4ased on my %nowledge and perception of the applicant. I understand that the information will 4e %ept confidential and will 4e used 4y the local CI ! Chapter in the e=aluation of the youth applicant.

ignature _____________________________________________________Date_______________________