UVA Health Auxiliary
UVA Health Prince William Medical Center
Teen Volunteer 2025 Summer Program Reference Form
Applicant’s Name _____________________________________ Date: _____________
The person named above has applied to UVA Health Prince William Medical Center for a volunteer position.
Participation in the Summer Teen Volunteer Program requires a high level of maturity, responsibility, and
commitment. Applicants are accepted based on their application, recommendations, and group interview.
Please take the time to honestly evaluate the above named applicant by (1) completing the check-list below
and (2) answering the questions on the reverse/added page of this form. Thank you in advance for your
time to evaluate this applicant. Also, please be sure to sign the reference form. A lack of signature
invalidates the form.
Your Name: __________________________________________ Your e-mail: ____________________
Your phone number ____________________ If we may call you, best time to call: __________________
Your relationship to the applicant: ____________________
Length of time you have known the applicant: ____________________
If you are a teacher, please indicate the subject(s) in which you taught the applicant. ________________
Evaluation Criteria for Ranking
To Observe
Opportunity
Frequently
Usually
Always
Rarely
Please rank this applicant using the criteria
No
listed below.
Applicant displays conduct appropriate to a setting.
Applicant works well with peers and adults.
Applicant completes assigned tasks.
Applicant accepts responsibility for assigned tasks
and personal behavior.
Applicant listens and follows instructions.
Applicant demonstrated effective oral communication.
Applicant is resourceful and self-reliant with new
situations
Applicant demonstrates respect for others, accepts
supervision, and treats others with kindness
Applicant acts appropriately in a given situation.
Applicant is punctual
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Applicant Name______________________ page 2 of 2
Please briefly answer the questions below.
1. If you were a patient or employee at a hospital, would you like this applicant to be
assigned to your area? If no, please explain.
2. To your knowledge, has this applicant been subjected to any disciplinary action? If
yes, please explain.
3. What characteristic(s) distinguishes this applicant from others?
4. Is there any additional information that may be relevant to this situation?
Important: When you have completed the reference form, please give back to the applicant in a signed
sealed envelope for submission. If you have any questions or concerns, please contact the UVA Health
Prince William Medical Center Volunteer Services office for the Summer Teen Program at 703-369-8173.
Evaluator’s printed name: ___________________________ ___________________________________
(First Name) (Last Name)
Evaluator’s signature: __________________________________________________________________
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