Child Safety

Youth and Child Care Worker Reference Request

Applicant Name: ______Date: ______

Please provide the name and contact information for three references, including at least one who has direct experience of your work with children or youth and at least one who is a professional or institutional reference, rather than a personal one. Family members and employees of FGC cannot be used as references. Email addresses are the most useful with a phone number to use for follow-up.

Reference 1

Name: ______

E-Mail: ______Phone number: ______

(for use when there are email glitches only.)

Reference Type (underline all that apply):

Experience with ChildrenProfessional/InstitutionalPersonal

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Reference 2

Name: ______

E-Mail: ______Phone number: ______

(for use when there are email glitches only.)

Reference Type (underline all that apply):

Experience with ChildrenProfessional/InstitutionalPersonal

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Reference 3

Name: ______

E-Mail: ______Phone number: ______

(for use when there are email glitches only.)

Reference Type (underline all that apply):

Experience with ChildrenProfessional/InstitutionalPersonal

PLEASE CONTINUE ON OTHER SIDE

Monthly Meeting Verification

All youth and child care workers who will serve for the duration of the event must be active in a monthly Meeting for at least six months prior to serving. This must be verified with the clerk of the Meeting. Please provide the name and contact information for your Meeting’s Clerk. Email addresses are the most useful with a phone number to use for follow‐up.

Monthly Meeting: ______

Length of time attending this meeting: ______

Clerk Name: ______

E-Mail: ______Phone number: ______

(for use when there are email glitches only.)

If you have been attending your current meeting for less than 6 months, please provide the contact information from your previous meeting:

Monthly Meeting: ______

Length of time attending this meeting: ______

Clerk’s Name: ______

E-Mail: ______Phone number: ______

(for use when there are email glitches only.)

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After completing this form, save it on your computer with your name. Email it as an attachment to the Junior Gathering Coordinator, Patsy Arnold Martin at

If you cannot email attachments, print this out and mail it to:

Junior Gathering Coordinator

Friends General Conference

1216 Arch Street, Suite 2B

Philadelphia, PA 19107