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ST. JOHN CANADA INSTRUCTIONS

2-9-2ap6

 

Sample

ST. JOHN AMBULANCE

Volunteer Reference Form

 

PLEASE PRINT.

Name of person giving reference  

 

Address  

 

(number & street) (city) (Province) (postal code)

Res. Telephone  

Bus. Telepone

 

 

PLEASE ANSWER THE FOLLOWING TO THE BEST OF YOUR KNOWLEDGE.

 

1. How well do you know the applicant?

Slightly __ A little well __ Quite well __

2. How long have you known the applicant? ______________________________________

3. In what capacity have you known the applicant? What is your relationship to this person? (Friend? Service Club? Work? Please specify.)

__________________________________________________________________________

4. Below, please check ONLY those characteristics you have had the opportunity to observe.

þ

Poor

Fair

Good

Excellent

No Knowledge

Ability to get along with others          
Emotional stability          
Dependability          
Initiative          
Integrity          
Assertiveness          
Capacity to assist people          
Problem-solving ability          
Adaptability          
Willingness to accept direction          
Personal appearance          
Ability to express opinions constructively          
Respect for others          
Leadership qualities          
Ability to maintain composure in stressful situations          
Perseverance with regard to difficult tasks          

 

5. Please check any of the following personality traits which best describe the applicant: þ

 

q Active

q Friendly

q Organized

q Shy

q Aggressive

q Happy

q Outgoing

q Sincere

q Arrogant

q Honest

q Patient

q Superficial

q Caring

q Humble

q Punctual

q Tactless

q Compassionate

q Insincere

q Reliable

q Tolerant

q Confident

q Irresponsible

q Responsible

q Understanding

q Controlling

q Judgmental

q Self-confident

q Warm

q Domineering

q Lazy

q Self-conscious

q Withdrawn

q Easygoing

q Mature

q Selfish

q Other (please

q Energetic

q Nervous

q Sensible

specify)

q Flexible

q Opinionated

q Serious

 

 

6. What are the applicant’s personal strengths?

_______________________________________________________________

______________________________________________

7. What are the applicant’s personal limitations?

_______________________________________________________________

______________________________________________

8. How well does the applicant work with others?

q Extremely well

q Well

q Average

q Marginally

q Poorly

 

Comments__________________________________________

9. How effectively does the applicant work independently?

q Extremely well

q Well

q Average

q Marginally

q Poorly

 

Comments__________________________________________

10. Being a St. John Ambulance Brigade volunteer involves working with, and in some positions, providing first aid treatment for anyone in need, regardless of any other consideration except that of personal safety (i.e. violence or civil

disturbance). This includes people of all ages from young children to senior citizens. It also includes no regard for their creed, colour, ethnic origin, gender, social status, or disability. Do you know of any reason, limitation, or situation that makes you feel the applicant would have difficulty providing assistance to a total stranger?

_______________________________________________

________________________________________________

 

11. Some positions require approximately forty hours of initial training, regular weekly attendance at meetings (about two hours per week) and an average of five additional hours of volunteer work per month. Do you feel the applicant will have sufficient time to make a meaningful contribution to St. John Ambulance without sacrificing their other obligations?

YES / NO (Please give reason for your answer)

______________________________________________

______________________________________________

11. Would you choose this applicant to help YOU or your child if the need arose? (Why or why not?)

______________________________________________

______________________________________________

12. Would you recommend this applicant as a St. John Ambulance Brigade volunteer?

(Why or why not?)

______________________________________________

______________________________________________

 

Signature: _______________________________ Date: _________________________

Position/Occupation: _____________________________________________________

Home phone # ______________________ Work phone # ______________________

 

 

THANK YOU FOR YOUR ASSISTANCE.

 

PLEASE RETURN THE COMPLETED FORM DIRECTLY TO

ST. JOHN AMBULANCE.


DO NOT RETURN THIS FORM TO THE APPLICANT FOR HAND DELIVERY.

(Place your District address, fax # and contact name here)


Information Request about St. John Instructions - Part II

Name
Rank\Title
Unit
Comment
or question
E-mail
Phone (Optional)

Send mail to Don Smith with questions or comments about this web site.
Copyright © 1997 St. John Ambulance Cadets of Ontario
Last modified: August 17, 1998