Reference Form Please fill out this Reference Form to the best of your knowledge. All information will be held in confidence. Thank you. I, am submitting this reference on behalf of: Applicant 1: Applicant 2: (if applicable) who is applying to the Family Beacon program as a:Beacon HomeHome CoachClient Coach 1. In what capacity have you known the applicant(s) and for how long? 2. To your knowledge, has this applicant(s) ever been convicted of a crime? YesNo If yes, please explain. 3. Would you consider placing the responsibility of your child or another relative with the above reference applicant(s)? YesNo If no, please explain. 4. What three words best describe the above applicant(s)? 5. What else can you tell us about the applicant(s) that you think Family Beacon should know? Electronic Signature: Please type your First and Last Name Date (MM/DD/YYYY) Phone Church Name (if applicable) Relationship