Peer Support Volunteer application form

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Counterpart application form: Peer Support Volunteer

PRIVATE AND CONFIDENTIAL

Counterpart is committed to protecting your privacy and the confidentiality and security of personal information provided by you to us. Consistent with the relevant privacy legislation, we ensure that your personal information will not be disclosed to others, except if required by law or other regulation.

Thank you for your interest in Counterpart and your willingness to apply to be part of our volunteer program. Please complete the following information to help us gain a better understanding of you and your cancer experience.

Applications close on Monday 21 April 2025.

To save your progress to continue later, please click on ‘Save and Continue Later’, located at the bottom of the page.

We strongly recommend that you read the Peer Support Volunteer Position Description before completing this form.

Contact details

Your Name(Required)

First

Last

Your preferred pronouns

(e.g. she/her, they/them)

Your address(Required)

Street address

Address line 2

City / suburb

State

Postcode

Your preferred phone number(Required)

Your Email Address(Required)

Email Address

Confirm Email Address

Would you like to be included on our mailing list?

Yes

Already on

Subscribe to receive our monthly newsletter.

Part 1 – About you

Date of birth

Country of birth

Are you of Aboriginal or Torres Strait Islander origin?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, Aboriginal and Torres Strait Islander

Prefer not to say

Do you speak a language other than English?

Yes

Please specify language/s spoken?

Are you:

Single

Partnered

Widowed

Do you have children?

Yes

How old are they?

How did you hear about the Counterpart Peer Support Volunteer program?

What interests, experiences and skills can you offer Counterpart as a volunteer?

Have you previously worked as a volunteer?

Yes

Please tell us about your previous volunteering experience?

What are your reasons for wanting to volunteer with Counterpart?

What would you like to gain from your volunteering experiences with Counterpart?

I understand that if my application is successful, I will be required to undergo a Police Check.(Required)

Yes

The cost of this will be covered by Counterpart.

Part 2 – Volunteer training

The Peer Support Volunteer training will be conducted online at your own pace and will include a compulsory* in person attendance at an induction day for all new volunteers. Volunteers from the Greater Geelong region can choose to attend the induction day in Geelong or Melbourne CBD.

Do you live in the Greater Geelong region?

Yes

The training will also include one day of live online workshops as well as face-to-face “on-the-job” learning on a regular basis for those who can travel to the Melbourne CBD .

Trainee volunteers from Geelong or regional Victoria will have the option of partaking this “on-the-job” training online with experienced volunteers.

* Counterpart will reimburse regional trainees for the cost of travel to either Melbourne (or Geelong for those living in Greater Geelong area) for the induction day.

I am available to attend the in-person induction day:

NB. Please note that attendance is required. If you can’t arrange to attend on this day, you may wish to apply for our next intake.

I can attend in Melbourne CBD on 3 June 2025.

Yes

I can attend in Geelong on 17 June 2025 (date to be confirmed).

Yes

I am available to attend on-the-job training in Melbourne CBD.

Yes

I live outside of Melbourne and will require 'on-the-job' training online. I have access to a computer and internet.

Yes

Part 3 — Your availability

Upon the successful completion of the training which days will you be available to volunteer?

Days available:

Monday

Wednesday

Thursday

Frequency:

Fortnightly

Other (please specify)

Other frequency

If the need arises while volunteering, would you be prepared to use your car?

Yes

Are there any current health issues that you feel we should be aware of?

Part 4 – Your cancer experience

What type of cancer/s have you been diagnosed with? Please provide details about type/s and month/s and year/s of your diagnosis.

Have you been diagnosed with advanced (metastatic) cancer?

Yes

If so, when was it diagnosed (approx)?

If you had surgery, what type of surgery/ies did you have? Please indicate if you have had multiple surgeries as a result of your cancer (breast reconstruction, stoma, plastic surgery etc)

Did you have any of the following treatments?

Chemotherapy

Radiotherapy

Brachytherapy

Hormone therapy

Herceptin

Immunotherapy

Have you been diagnosed with lymphoedema?

Yes

Have you had genetic testing relating to your cancer?

Yes

If yes, what was the result?

Is there any other information you would like to tell us about your cancer experience and treatments?

Part 5 – Other information

Is there anything else you would like to tell us about yourself?

Please provide the name, address and telephone number of a referee whom we can contact. This can be a relative, friend, work colleague or anyone else that you would be happy for us to speak to. Please explain their relationship to you.

Referee name

First

Last

Referee phone (home)

Referee phone (business)

Referee's address

Street address

Address line 2

City / suburb

State

Postcode

Referee's email address

Referee's relationship to you

Thank you for providing the above information to us. If you have any queries or concerns, please contact Kellie Holland, Volunteer Coordinator on 03 9921 0834 or email [email protected]

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[email protected]

[email protected]

Peer Support Volunteer application form

Application form: Peer Support Volunteer