Women's Crisis Service Volunteer Crisis Intervention Worker Personal Reference Check

Name of Applicant:______________________________ Date:__________________ Reference Name & Address:_______________________ Phone:________________ How long have you known this applicant?____________________ In what capacity and how well do you feel you know him or her?_______________ ______________________________________________________________________ What are some of his or her strong qualities?______________________________ ______________________________________________________________________ Do you have any concerns about this applicant working with victims of domestic violence and/or sexual assault?___________________________________________ _______________________________________________________________________ How responsible is the applicant? Very______ Usually______ Seldom______ Irresponsible______ Unknown______ To what extent does the applicant follow through on commitments? Always______ Usually______ Sometimes______ Seldom______ Never______ Describe, if you can, what you believe this applicant's strong points might be in working with the client population that WCS serves.____________________________________ __________________________________________________________________________ Please evaluate this individual on: Excellent Good Fair Not Sure Ability to cope with problem situations: [ ] [ ] [ ] [ ] Ability to adjust to expectations of others: [ ] [ ] [ ] [ ] Acceptance of people with different backgrounds and beliefs: [ ] [ ] [ ] [ ] Sense of humor: [ ] [ ] [ ] [ ] Interest in community: [ ] [ ] [ ] [ ] Ability to communicate: [ ] [ ] [ ] [ ] Do you know of any reason why the applicant would not serve well as a volunteer?________________________________________________________________ __________________________________________________________________________ If you have additional information or comments that you feel would be helpful to us, please include them in the space below. If you would like to further discuss your answers, please call Women's Crisis Services at (603)352-3782. The information you provide on the volunteer will be held in confidence by our agency. It is not shared with the volunteer. Thank you for your cooperation. Date:____________ Signature:_______________________________ ----------------------------------------------------------------------------------------------------------------------- Volunteer Permission By signing below, I give my permission to _________________________ to provide a character reference for information regarding my skills to be a volunteer for Women's Crisis Services. Date:______________ Signature________________________________

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Women's Crisis Services is a Monadnock United Way Agency. Women's Crisis Services of the Monadnock Region, 12 Court St. Keene, NH. 03431 Women's Crisis Services of the Monadnock Region, 47 Peterborough St. Suite B, Jaffrey, NH. 03452 All graphics are the property of Women's Crisis Service's of the Monadnock Region, and New Hampshire Coalition Against Domestic and Sexual Violence, © Copyright 2002

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