Youth Applicant Reference Chapter Selection Chair Judy Eshlemen Phone: 937-638-4867 Email: midwestohio-selectionchair@cisvusa.org Youth Delegate Reference Form Step 1 of 4 25% The following is a recomendation for a youth aplicant for a CISV programDelegates Name(Required) First Last What program is the youth applying for? Village (Peace Education Camp for 11 year olds) Youth Meeting (Peace Education Camp fpr 12-13 year olds) Step Up (Peace Education Camp for 14-15 year olds) Fortnight (Peace Education Camp for 16-17 year olds) If selected, the youth applicant will represent the United States and their own area in an international setting. The local CISV USA Chapter requests your help in identifying applicants who exhibit leadership qualities and can represent their own culture successfully*This form must be completed and received no later than January 15 of the program year* Name of reference First Last OccupationPhoneEmail In what capacity do you know the youth applicant?If you are the youth applicants current teach, what is your school's name?School's PhoneOnly needed if you are the youth delegates current teacherHow long have you known the youth delegate? Please select all atributes you believe the youth applicant displays Mature Independent Responsible Expresive Accepting Discerning Shows Inititive Optimistic Pesimistic Responsive Cooperation Cautious Curious Attentive Practical Helpful Participates Needs Coaxing Caring Spontaneous Reticent Open-Minded Respects Adults Respects Peers Follower Leader Team Player Fair-Minded Organized Dependent Creative Quiet Secure Vivacious Sensitive Forgetful Introspective Friendly Articulate Accepted Unusual Sincere Healthy Confident Tolerant Compromiser Intense Mild-Mannered Patient Hurried Studious Motivated Disrespectful Athletic Artistic Outgoing Inward Intolerant Flexible Follows Direction Fun Conscientious Shares Talkative Adventurous Use this area to elaborate on any of the atributes above or to share any concerns you might have.Keep in mind we are looking for youth who compliment each other when forming program delegations. There is no set profile of a "typical" or "ideal" youth delegateDo you know of any special talents or experiences that would help this youth applicant contribute to an international program?The information provided above has been thoughtfully and honestly given, based on my knowledge and perception of the youth applicant. I understand that the information will be kept confidential and will be used by the local CISV Chapter in the evaluation of the youth applicant. intolerance, violence or lack of self-control, sexual contact, verbal abuse of others, and inability to handle a reasonable amount of stress. If you have seen the youth applicant exhibit such behaviors, please explain in the space below or call the Chapter contact person at the phone number listed on the front of this form.The information provided above has been thoughtfully and honestly given, based on my knowledge and perception of the youth applicant. I understand that the information will be kept confidential and will be used by the local CISV Chapter in the evaluation of the youth applicant. intolerance, violence or lack of self-control, sexual contact, verbal abuse of others, and inability to handle a reasonable amount of stress. If you have seen the youth applicant exhibit such behaviors, please explain in the space below or call the Chapter contact person at the phone number listed on the front of this form.The information provided above has been thoughtfully and honestly given, based on my knowledge and perception of the youth applicant. I understand that the information will be kept confidential and will be used by the local CISV Chapter in the evaluation of the youth applicant.The information provided above has been thoughtfully and honestly given, based on my knowledge and perception of the youth applicant. I understand that the information will be kept confidential and will be used by the local CISV Chapter in the evaluation of the youth applicant. Signature(Required)
