Volunteer Form

Your Name: (required)

Address:

Postal code:

Telephone
Home:
Cell:
Work:

Your Email: (required)

Best time to call: ampmevening

Date of birth:
(While this is optional, it will help us greatly in compiling our statistics)

Age range: 18-2425-3435-4950-6465-7475+

Languages
Spoken: EnglishFrench   Other:
Written: EnglishFrench   Other:

Education: High-schoolUniversityPost-graduate

Experience and skills
Describe your work experience

Describe your volunteer experience

Describe any specific skills or hobbies which would be useful to your work as a volunteer
(also make note of any computer skills)

Cancer experience
Cancer diagnosis
   Date:
   Diagnosis:

Diagnosis of family member(s)
   Date:
   Diagnosis:
   Date:
   Diagnosis:
   Date:
   Diagnosis:

Diagnosis of a close friend
   Date:
   Diagnosis:

No experience

Other

Chemo - What type?HormonalRadiotherapy
What was the experience like? Describe your experience (treatments, outcomes, etc.)

Have you lost a family member or close friend to cancer? If so, when:
Please describe your experience of this loss?

Motivation - Please describe how you heard about Hope & Cope and your reasons for applying to volunteer in the program.

Coping - What helped you to cope with the difficult issues related to your personal experiences with cancer? And/or with your experiences with loss?

Please describe the strengths you feel you have for volunteer work in this program.

As this is an understandably difficult area in which to work, please describe any concerns you have and the help you feel you would need to work effectively.

Please give the name and phone numbers of THREE references (either personal or professional)
            Name:
           Phone:
Relationship:
            Name:
           Phone:
Relationship:
            Name:
           Phone:
Relationship:
Permission for police check: YesNo

Please indicate the day / schedule you hope to follow
(prioritize your 1st and 2nd choices)

First choice
Mondayampmevening
Tuesdayampmevening
Wednesdayampmevening
Thursdayampmevening
Fridayampmevening
Saturdayampmevening
Sundayampmevening

Second choice
Mondayampmevening
Tuesdayampmevening
Wednesdayampmevening
Thursdayampmevening
Fridayampmevening
Saturdayampmevening
Sundayampmevening

Please select the areas in which you are interested in volunteering
Hospital VisitingPalliative Care Volunteer Program (4Main)Peer Counselling / MentoringOncology / Radiotherapy ClinicsSelf-Help Group FacilitatorPR and/or Education of Volunteers & PublicOffice - TypingOffice - Familiar with computersOffice - Familiar with data base entryDeveloping and Updating Resource Information & Educational ToolsLibraryCoping Skills TrainingComplementary Therapies - Relaxation Training, Art Therapy, Yoga, Qi Gong, Massage, etc.Bereavement ProgramNewsletter publicationWebsite developmentWellness Centre - Exercise, Nutrition, Office Reception, Registration, etc.Fundraising - Friends of Hope & CopeFundraising - Young Adult Division (Denim & Diamonds)Fundraising - Other


Confidentiality
I will respect the right of the patients and their families to strict confidentiality concerning; the diagnosis, prognosis, family dynamics and any information of a medical, spiritual or psycho-social nature. This information is shared with me as part of a sacred trust and I will divulge none of it to others.

Training and on-going learning
I will attend the Hope & Cope orientation sessions, the McGill training program for Palliative Care volunteers (if applicable) and attend educational programs arranged for volunteers within the department, as part of my commitment to continuous on-going learning.

Respecting the schedule
I will respect the schedule arranged for me during my probationary period in order to shadow my partner, and keep to the schedule which I later establish in collaboration with the Volunteer Coordinator. I will notify theVolunteer Coordinator of any change of schedule, within a reasonable delay, and attempt to find a replacement volunteer for my shift.


I have read and acknowledge the above terms:

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