Motivation (Desire to learn)	--- Select One --- Very ambitious Average Indifferent Purposeless
Enthusiasm	--- Select One --- Excellent Good Fair Poor
Loyalty	--- Select One --- Excellent Good Fair Poor
Emotional Maturity (self-control)	--- Select One --- Very Stable Well-Balanced Average Below Average Unstable
Social Acceptability (response from others)	--- Select One --- Sought out Well-liked Accepted Tolerated Avoided
Tolerance	--- Select One --- Excellent Good Average Fair Poor
Energy	--- Select One --- Excellent Good Average Fair Poor
Responsibility	--- Select One --- Always Assumes Often Seeks Accepts Avoids Never accepts
Communication	--- Select One --- Excellent Good Average Fair Poor
Social Attitude (concern for others)	--- Select One --- Very Concerned Interested Average Indifferent Anti-social
Humor	--- Select One --- Excellent Good Average Fair Poor
Understanding Children	--- Select One --- Excellent Good Average Fair Poor
Leadership	--- Select One --- Always leads Frequently Leads Seldom leads Follower Negative
Ability to Accept Supervision & Guidance	--- Select One --- Excellent Good Average Fair Poor
Summary	--- Select One --- Outstanding Above Average Average Fair Doubtful

Why would the applicant make a good staff member?

Any additional comments you wish to make :

To the best of your knowledge has applicant ever --- Select One --- Yes No Not Applicable
had any criminal convictions
for child sexual abuse offenses?


Has applicant ever had any criminal convictions? --- Select One --- Yes No Not Applicable

Your Full Name:
Your Email Address:	(Required)

School/Company Name:

School/Company Address (street, city, state, zip):

Home Phone Number:
Evening Phone Number:

Home Address (street, city, state, zip):