Volunteer Reference

An applicant has applied to become a volunteer at St. Jude Children's Research Hospital and has given your name as a reference. St. Jude is a pediatric hospital serving patients with cancer and other catastrophic diseases. We appreciate you taking the time to complete this form. The information you provide will remain confidential.

Asterisk (*) indicates a required field.

Applicant Name*

What is your relationship to this person? (relatives are excluded)*

Friend Co-worker Employee Other

How long have you known this person?*

Less than 1 year 1-2 years 3 years or more

Do you believe you know this person well enough to evaluate strengths and weaknesses?*

Yes No

Applicant Evaluation

Please check the number you feel best describes or fits this volunteer with one (1) being inadequate and five (5) being exceptional.

5. Ability to be a good listener and refrain from taking charge of another person's problems (offering opinion, providing solutions, giving medical or religious advice)*

6. Acceptance and sensitivity to differences in others (values, cultures, socio-economic class, race)*

8. Ability to work well with children, even teenagers (note: not all volunteers work with patients)*

Comments

Reference Contact Information

Your Name*

Your Phone*

Date*

I agree to share this information with St. Jude*
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