Cadets Online: St. John Instructions - Part II

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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q Domineering	q Lazy	q Self-conscious	q Withdrawn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