Volunteer Reference Form
____________________________________ has recently applied to be a volunteer at Open Door Family
Medical Centers. Volunteers are required to supply references from two non-family members. If the volunteer
service pertains to a school community service or educational program, one reference form must be from a
teacher or advisor of the school.
1. How long have you know the applicant? ________________________________________
2. In what capacity have you know the applicant?
Employer _______
Past Employer ______
Teacher/Counselor ______
Leader of faith-based organization _____
Leader/Supervisor of community organization ______
Other, please indicate: _______________________________________________________________
3. Please rate the applicants work ethics: 1: Outstanding 2: Effective 3: Satisfactory 4: Unsatisfactory
Quality of work ____
Productivity ____
Conduct ____
Dependable ____
Personal Appearance ____ Punctuality ____
Attendance ____
Cooperation ____
4. What skills does the applicant have that will be beneficial in a volunteer role? Please Comment.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Would you recommend the applicant as a qualified, responsible and courteous volunteer?
Please Comment: ___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. Is the applicant is volunteering as part of a school initiated program? ___________________________
Name of program: ___________________ Hours/weeks needed: _____________
Program Coordinator: ________________ Phone Number: ___________ Email: ______________
Please include a copy of the program guidelines and sponsor’s responsibilities.
______________________________
Name (Please Print)
_____________________________
Signature
___________________
Date
______________________________
Company/Organization
_____________________________
Title/Position
___________________
Phone Number
Your response will be held in strict confidence. If there is any information you prefer to discuss personally,
please call me at (914) 502-1468. Please return this form directly to Open Door via email: [email protected],
fax: (914) 941-3270 or mail: Alicia Ward, Volunteer Coordinator, Open Door Foundation, 2 Church Street Suite 101, Ossining, NY 10562.
Thank You,
Alicia Ward, Volunteer Coordinator
Open Door office use: Received: ____________ Called: ____________