CMAWPA - Counselor Reference Form

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District Ministries > Disciplemaking Ministries > Youth Commission > Counselor Reference Form

COUNSELOR REFERENCE FORM

A Counselor Reference Form is required for each Counselor/Youth Leader who will be attending the WPA C&MA District's Youth Events, Breakaway (Senior High Retreat) and Jolt (Junior High Retreat). Official Workers are exempt. The form is to be completed by the senior pastor or other authorized personnel and returned to the District Office.

Each group attending must bring at least 1 counselor for every 5 male or female students. Counselors should be at least 22 years of age or older. Please only request permission for counselors who understand the seriousness of their responsibility. Special requests should be directed to the Director of Disciplemaking Ministries.

Please complete an online form for each Counselor/Youth Leader. See below.

Name of Event:
Name of Church:
Name of Counselor:
Name of Pastor or Elder:
Phone Number:	( ) -
Email Address:
Please answer the following questions.
How long have you known the applicant?:
In what relationship have you known the applicant?:
Will the applicant make a good counselor for our youth?:
What strengths does this person have to make him/her qualified?:
What are this person's weaknesses?:
If you answer yes to any of the following questions, please provide complete details to the best of your knowledge.
Has the applicant ever engaged in any conduct/behavior which was immoral or had the appearance of impropriety?:
Has the applicant ever been or suspected of engaging in inappropriate sexual activity/relationship/behavior?:
Has the applicant ever been charged with or convicted of a criminal offense?:
Do you wholeheartedly recommend this person to counsel at this youth event? Please describe any reservations.:
Yes I Approve.: