| ID | EGM-HR-09 | Name | Volunteer & Therapist Application Form |
|---|---|---|---|
| Revision | 3 | Approved By | Jacqueline Daly |
| Approved Date | 01/02/2024 | Review Date | 2025 |
References & Definitions
East Galway & Midlands Cancer Support: EGM
Volunteer/Support Worker: Someone who offers their time/service to EGM without expectation of reimbursement
EGM-MA-01 Master List of Policies and Procedures
Implementation
Please Complete the Following in Block Capitals.
Name: ______________________________________________________________________________________
Address: ______________________________________________________________________________________
Street ______________________________________________________________________________________
Town: ______________________________________________________________________________________
County: ______________________________________________________________________________________
Eircode: ___________________________________
Home phone: ____________________________________________________
Mobile Phone: ___________________________________________________
E-Mail Address: _______________________________________________________________________________
I.C.E Contact Name: _____________________________________________
I.C.E Contact Number: ___________________________________________
Date of Birth: ______ / ______ / ______
Additional information relating to your application
Please indicate the day/s that you would be available:
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Morning
- Afternoon
- Evening
Why do you want to volunteer with EGM? ___________________________________________________________________________________________________
Have you had any training that would be relevant in your work as a volunteer / therapist? ___________________________________________________________________________________________________
What do you hope to gain from being a volunteer / therapist? ___________________________________________________________________________________________________
What qualities would you bring to your work in the centre? ___________________________________________________________________________________________________
What are your interests or hobbies? ___________________________________________________________________________________________________
Have you had a cancer diagnosis?
- Yes (If Yes, please complete section A)
- No
Have you had a relative or a close friend who has had a cancer diagnosis?
- Yes (If Yes, please complete section B)
- No
Section A
Details of Cancer diagnosis: ____________________________________________________________
Date of diagnosis: ______________________________________________________________________
Treatment:
Surgery: □ Chemotherapy: □ Radiotherapy: □ Hormone Therapy: □ Other: □
Recurrence:
Details of recurrence: ____________________________________________________________
Date of recurrence: ______________________________________________________________
Treatment:
Surgery: □ Chemotherapy:□ Radiotherapy:□ Hormone Therapy:□ Other:□
Section B
Relationship to the person with the cancer diagnosis? _______________________________________
What was your experience of being involved with a person with a Cancer diagnosis? ___________________________________________________________________________________________________
Details of the Cancer Diagnosis: ____________________________________________________________
Date of diagnosis: __________________________________________________________________________
References
1
Name: ____________________________________________________________
Organisation: _____________________________________________________
Position: __________________________________________________________
Contact Number: __________________________________________________
2
Name: ____________________________________________________________
Organisation: _____________________________________________________
Position: __________________________________________________________
Contact Number: __________________________________________________
DECLARATION
I certify to East Galway & Midlands Cancer Support CLG that the information I provided herewith is true and correct.
If I am a successful candidate, I agree to being processed for clearance by An Garda Siochana.
- I consent to East Galway & Midlands Cancer Support storing the above personal information.
- I consent to East Galway & Midlands Cancer Support using the above information to contact me with updates / improvements / additions to their services, with a newsletter containing information about previous and upcoming events.
- I confirm that I have/will read and agree to abide by all of the policies and procedures relating to East Galway & Midlands Cancer Support.
Signature: ______________________________ Date: ______ / ______ / 20____
Office Use Only
- Support Worker/Therapist Entered into Database
- Support Worker/Therapist # from Database __________________
- Garda Vetting received for Support Worker/Therapist
- Database Updated with Garda Vetting Receipt
- Domain account created for Support Worker/Therapist by IT (If applicable)