VOLUNTEER SERVICES

REFERENCE FORM

APPLICANT INFORMATION
Name of Applicant:

Dear Referee: As part of the application process to become a volunteer at Humber River Hospital, we
would appreciate your assistance in providing a reference for the above noted individual. Please
complete this form with as much detail as possible and forward directly to Volunteer Services in
confidence by clicking this link: lramdial@hrh.ca . Thank you for your time.

REFEREE INFORMATION
Name of Referee: Phone:
Organization: Email:
Position Title:
Relationship:
(Select one) Manager/Supervisor Teacher Other:
How long have you known the applicant?

The applicant noted above has asked me to provide a reference in support of their application to
volunteer at Humber River Hospital. I understand that:
i) as a volunteer, this individual will have contact with patients, families, visitors and staff;
ii) volunteer activities can include patient and family support, comfort, greeting, customer
service, and working in positions of trust and confidentiality; and
iii) I have known the applicant for a minimum of 6 months or more.

EVALUATE THE APPLICANT’S SKILLS

Unable
Competency and Work Ethic Poor Fair Good Excellent
to Judge
Communication and Interpersonal Skills
Compassion for others
Respect for others
Customer Service Skills
Reliability and Dependability
Ability to receive and follow instructions
Ability to work independently and take initiative
Trustworthiness
Cooperation
What would you say are the applicant’s best qualities, characteristics and or/strengths?

Knowing the potential volunteer activities the applicant may be involved in, do you have any issues
or concerns?

Please select the most appropriate box and add a comment if necessary.

Do you consider the applicant suitable to be a volunteer at Humber River Hospital knowing he/she
may not receive direct supervision? Yes No

Comments:

If you or a family member were a patient at Humber River Hospital, would you want this person to
visit you? Yes No

Comments:

Please add any additional comments:

All information provided is CONFIDENTIAL. Please return the completed form within 1 week of receipt.

Referee Signature: Date:_______________________

Thank you for your time and assistance in completing this reference form.