Reference – Medical Clearance Reference Check – Medical Clearance About YouYour Name:(Required) First and Last Your Business/Organization's Name (if applicable): Your Phone Number:(Required)Your Email Address: About the ApplicantName of person reference is being provided for:(Required) First and Last 1. How long have you known the applicant and in what capacity?2. What is the frequency of your contact? 3. Is the applicant currently recovering from, or do they have any physical illness or injury (past or present) that may possibly impact their relationship with a child or ability to fulfill the mentoring role or commitment? Yes No Other 4. Please describe/name the physical illness/injury (and treatment) and how it may impact the applicant's ability to volunteer as a mentor to a young person.5. Is the applicant recovering from, or do they have any mental illness/mental health challenges (past or present), that may possibly impact their relationship with a child or ability to fulfill the mentoring role/commitment? Yes No Other 6. Please describe/name the mental illness/mental health challenge (and treatment) and how this may impact the applicant's ability to volunteer as a mentor to a young person.7. Is the applicant, or has the applicant ever been, drug and/or alcohol dependent? If yes, has the applicant ever sought or received counselling/treatment for drug or alcohol dependence? Please explain.8. From your perspective, does this applicant have the physical and emotional stability to volunteer as a mentor/role model and to build a safe and healthy relationship with a child at this time? Yes No I would like to discuss via phone call. Other 9. Is there anything you would like to add that would aid us in our decision?CommentsThis field is for validation purposes and should be left unchanged.
