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Peer Connect – Gene Volunteer Application

Thank you for your interest in volunteering with the Peer Connect – Gene 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 Peer Connect Manager on 03 9514 6315 if you need any help or have any questions about this form.

Contact details

Title (optional)

First name

Last name

Date of birth

Street Address

Suburb

Postcode

Phone number (optional)

Mobile (optional)

Please mark the most appropriate response to the following questions

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 LGBTI? (optional)

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

When was your genetic testing? (month/year)

What is the gene type?

Did you receive Genetic Counselling prior to being tested?

Have your children, or any other family members, been tested? (if applicable) (optional)

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?

Regular screening with no intervention? (optional)

If yes, what type of screening?

Prophylactic surgery (optional)

If yes, what type of surgery?

Hormone therapy (optional)

If yes, what type?

Other (optional)

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

Verification

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

Have you been diagnosed with cancer? If yes, what type of cancer were you diagnosed with? (optional)

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

In what month and year were you diagnosed? (optional)

In what month and year was the cancer treatment completed? (optional)

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

Surgery (optional)

Type of surgery (optional)

Date of surgery (optional)

Chemotherapy (optional)

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

Date of commencing chemotherapy (optional)

Radiotherapy (optional)

Radiotherapy type and area of treatment (optional)

Date of commencing radiotherapy (optional)

Hormone therapy (optional)

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

Date of commencing hormone therapy (optional)

Details of any other treatment (optional)

Further information

How did you hear about the Peer Connect - Gene volunteer position? (optional)

Briefly outline why you are interested in being a Peer Connect - Gene volunteer

What qualities and skills do you feel you will bring to the Peer Connect - Gene program?

Have you volunteered with Cancer Council Victoria before? If yes, please detail

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

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

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 Peer Connect - Gene 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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