CIPL Reference Form


Participant Information

First Name:
Last Name:
Street Address:
City:
State:
Zip:

TO THE PERSON RECOMMENDING THE PARTICIPANT:

You are being asked to be a reference for a parent who has applied to participate in the Commonwealth Institute for Parent Leadership. The Institute was established by the Prichard Committee for Academic Excellence to improve parent involvement in education. Parents who care deeply about their children’s education and who have leadership potential will be provided with additional knowledge and skills to become more involved in education and to help other parents become involved. For questions contact the Prichard Committee at 1-800-928-2111 or (859) 233-9849 ext. 231 or access our website: www.cipl.org . Our email address is cipl@prichardcommittee.org.

Your Contact Info

First Name:
Last Name:
Home Address:
Business Address:
City:
State:
Zip:
Home Phone Number:
Business Phone Number:
E-mail:

 
How long have you known this person?
How do you know this person?
How has this person been involved in his or her child/children's education at home, in the school and/or in the community?
Explain why you believe this person has leadership potential, and would be a good Commonwealth Institute for Parent Leadership attendee?

Leadership Survey

The following list indicates leadership characteristics.  Rate the participant on each:
Using the scale below, check the number that best represents YOUR response to each item.




Statement
 Rating
He /she knows nothing important gets done alone.
He /she finds that making things happen and doing a good job takes lots of planning.
He /she is often restless with the status quo.
He /she knows children teach them the important ideas about leadership and working with others.
He /she uses personal experiences to relate to others.
If He /she comes to a dead end, He /she finds another way to tackle the problem.
Co-workers and/or family say He /she follows through with his/her commitments.
He /she deals openly and honestly with conflict.
He /she likes to set goals and measure success.

 

 
Thank you for your assistance