You have been asked to be a reference. Please complete the following.

Your Name*

First Last

Your Address*

Street Address City State ZIP Code

Your Phone Number*

Volunteer Name*

This person has volunteered to serve as a guardian or conservator with the Kansas Guardianship Program. Please respond to the following questions to assist us in the process of screening the applicant. The information you provide will be kept confidential and not be released to the applicant or any other party without your written permission. Thank you for giving this your prompt attention.

1. How long have you known the applicant?*

What is your relationship to the applicant (friend, co-worker, relative, etc.)?*

Please rate the abilities and characteristics of the applicant with the following scale: 5 = high, 1 = low, DK = Don't Know

2. KGP seeks volunteers who are compassionate, caring and able to serve as personal advocates.

Appropriate in response to the needs of others.*

Interact with people of differing backgrounds and opinions.*

Interact with persons with mentally disabling conditions.*

Please comment on your ratings.

3. KGP seeks volunteers who are dependable and keep commitments.

Personal integrity and honesty.*

Independent and assertive.*

Fulfill commitments in a timely manner.*

Self initiative.*

Work with limited supervision.*

Maintain records and documents.*

Please comment on your ratings.

4. KGP seeks volunteers able to make wise and appropriate decisions regarding another person.

Willing to learn new information.*

Follow guidelines and procedures.*

Makes decisions with reason and logic.*

Please comment on your ratings.

5. KGP volunteers may handle another person's financial affairs such as managing finances, bill payment and maintaining accurate financial records.

Please comment.

6. Please give us a short evaluation of the applicant's character and abilities.*

KGP Online Reference Form