Catholic Social Services of the Miami Valley

922 W. Riverview Ave., Dayton, OH 45402

(phone: 937-223-7217; fax: 222-6750; jobs@cssmv.org)

VOLUNTEER REFERENCE FORM

(Name of Applicant) _____________________________ has applied at CSSMV for a volunteer position.
Would you please take a few minutes to complete this volunteer form and mail or fax it back to
Human Resources at the above address?
Name of Program(s) for which applicant is applying

Ermas House
Respite Care
Senior Visiting

Reference Name:

Teen Link
Food Pantry
Refugee Resettlement

Administration
Interfaith Care Team
Day Care

Other:
_____________
Practicum: _____________
Internship: _____________

________________________________________________________________________________

Please check whichever applies to applicant

Excellent

Good

Fair

Poor

Dependability
Ability to Work with Others
Ability to Accept Supervision
Willingness to Ask for Assistance
Attitude
Trustworthiness
Communication Skills
Responsible for Self
Ability to Make Good Judgments
Energy Level
Flexibility
Creativity
Openness to others values, lifestyles, cultures & interests
especially when interacting with people whose
backgrounds are different (age, ethnicity, religion,
socioeconomic level, education, race, etc.)

How long have you known the applicant? _______________ Relationship: __________________________________
What are the applicants greatest strengths?
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
Would you recommend this person as a volunteer in the above program(s)?
Why or Why not?

Yes

No

________________________________________________________________

Additional Comments regarding applicant:

_____________________________________________

____________________________________________________________________________________
References Signature: _____________________________________________
Staff Only: Person Taking reference by Phone:

Date: ____/____/____

_________________________________________ Date: ___/___/___