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Gene Connect Volunteer Application

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

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

  • Please read the form and make sure you have all of the information ready before you start filling it out.
  • It should take about an hour to fill in the form. You won't be able to save and come back later so you'll need to fill it out in one go.
  • Please contact the Cancer Connect Manager on 03 9514 6315 if you need any help or have any questions about this form.

Contact details

Please mark the most appropriate response to the following questions

Genetics and testing (please complete to the best of your knowledge)

If yes, what were their results?
If they haven't been tested, what is the reason? (e.g. age, choice)

What measures have you taken since being tested?

If yes, what type of screening?

If yes, what type of surgery?

 If yes, what type?

 

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

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

If no, please go the "Further information" section below

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

Further information

Referee

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 Gene 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.   

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