Cancer Connect Volunteer Application - Cancer Council Victoria

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Cancer Connect

Cancer Connect Volunteer Application

Thank you for your interest in volunteering with the Cancer Connect peer support program.

Eligibility criteria:

To be eligible to volunteer with our program you need to have completed your cancer treatment at least two years ago, and no longer than five years ago.

This two year period allows volunteers to be physically and psychologically prepared for the supportive role they will undertake while ensuring their treatment is current.

The following form requests detailed information about your cancer experience. We capture this so we have a good understanding of your cancer diagnosis and treatment so we can best match you with people that are going through a similar cancer experience.

Before completing the form:

The form will take approximately 1 hour to complete.
Please read the form carefully and make sure you have all of the information ready before you start filling it out as you won't be able to save and come back later.
If you need help with any of the questions please contact the Cancer Connect Manager on 03 9514 6315

Contact details

Title (optional)

First name

Last name

Date of birth

Street Address

Suburb

Postcode

Phone number (optional)

Mobile (optional)

Do you speak a language other than English at home? If yes, please state which language (optional)

Do you identify as being from Aboriginal and/or Torres Strait Islander descent? (optional)

Relationship status

Do you identify as being LGBTIQ+? (optional)

Do you have children?

When you were diagnosed, how old were your children? (if applicable) (optional)

Occupation (optional)

Your diagnosis and treatment summary (please complete to the best of your knowledge)

Verification

Please attach documentation to verify cancer diagnosis (i.e. doctor's letter or report)

What type of cancer were you diagnosed with?

In what month and year were you diagnosed?

In what month and year was the cancer treatment completed?

Please tick the type of treatment(s) you have had and provide further details on treatment type:

Surgery

Type of surgery (optional)

Date of surgery (optional)

Chemotherapy

Neoadjuvant Chemotherapy

State drug/course/length of treatment if known (optional)

Date of commencing chemotherapy (optional)

Radiotherapy

Radiotherapy type and area of treatment (optional)

Date of commencing radiotherapy (optional)

Hormone therapy

State drug/course/length of treatment if known (optional)

Date of commencing hormone therapy (optional)

Other treatment

Details of other treatment (optional)

Date of commencing other treatment (optional)

Did you experience any side effects (acute or chronic) as a result of your treatment? (optional)

Did you participate in a Clinical Trial as part of your treatment? (optional)

Please describe the type of clinical trial and year commenced (optional)

Genetic testing

Gene type (optional)

Date of testing (optional)

Outcome of testing (optional)

Further information

How did you hear about the Cancer Connect volunteer position?

Briefly outline why you are interested in being a Cancer Connect volunteer

What qualities and skills do you feel you will bring to the Cancer Connect program?

What are some of your hobbies/interests or community activities you have been involved in?

Have you volunteered with Cancer Council Victoria before?

If yes, please detail (optional)

Referee

Please provide the name of someone (not related) whom we may contact for a reference? (Doctor, Religious Minister, Employer etc.)

Contact details (phone/email)

Relationship to you

Please note all successful applicants will be subject to a Police Check

By completing this form, you have provided Cancer Council Victoria with your personal information, which includes your sensitive and health information.

We will use and disclose this information for the purpose of reviewing your eligibility for the Cancer Connect program and matching you with suitable participants in the program.

Cancer Council’s Privacy Policy and Collection Statement contains general information about how we will handle and hold your personal information, and how you can contact us to seek to access or correct your personal information or make a complaint. You should review this Privacy Policy and Collection Statement to ensure you are fully informed about these matters.

I have read and understood the Privacy Policy and Collection Statement

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Questions about cancer?

Call or email our experienced cancer nurses for information and support.

Contact a cancer nurse

Aboriginal communities

Charity ABN: 61426486715

Cancer Council Victoria would like to acknowledge the traditional custodians of the land on which we live and work. We would also like to pay respect to the elders past and present and extend that respect to all other Aboriginal people.