Peer Support Volunteer application

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 12 August 2022.

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

Questions with an asterisk (*) are compulsory.

First name*

Last name*

Address*

Street Address Address line 2 Suburb State Postcode Country

Preferred phone number*

Please enter the best number to contact you on during business hours.

Additional phone number

Email*

Would you like to be included on our mailing list?

Yes
No
Already on

Part 1 – Personal information

Answers to the following questions assist us to develop a volunteer group that comprises a diverse range of women.

1. Date of Birth*

2. Country of Birth*

— If not born in Australia, year of arrival

3. Do you identify as Aboriginal or Torres Strait Islander?*

Yes - Aboriginal
Yes - Torres Strait Islander
Yes - Aboriginal and Torres Strait Islander
No
Prefer not to answer

4. Do you speak a language other than English?*

Yes
No

— Please specify other languages spoken:

5. Are you:

Single
Partnered
Widowed

6. Do you have children?

Yes
No

— If yes, how old are they?

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

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

9. Have you previously worked as a volunteer?

Yes
No

— If yes, please tell us about it.

10. What are your reasons for wanting to volunteer for Counterpart?*

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

12. Training will be conducted from 9.30am–4.00pm on Tuesdays, starting 11 October for 6 weeks. If your application is successful could you be available to participate in this training program?*

Yes
No

If no, please contact Kellie Holland on 03 8488 9834 or email [email protected]

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

— Days:*

Monday
Wednesday
Thursday

— Frequency:*

Fortnightly
Other

— If other, please specify*

14. Is there any other information you would like to tell us about your availability?

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

Part 2 – Cancer experience

To ensure our volunteer group is made up of women with a range of different breast and gynaecological cancer experiences, could you please provide us with details of your cancer type and treatments undertaken? You may choose more than one option.

16. What type of cancer(s) have you been diagnosed with:*

17. Please provide the month and year of your first cancer diagnosis (approx).*

18. Please provide the month and year of your second cancer diagnosis (if applicable).

19. Have you been diagnised with advanced/metastatic cancer?*

Yes
No

20. If you had surgery to treat your cancer, what type of surgery did you have?*

21. What type of treatment(s) did you have?*

22. If you had chemotherapy, did you have it:

before your surgery
after your surgery

23. Have you had radiotherapy?*

Yes
No

— If so, was it:

Internal
External beam
Liquid
Other

— Please specify other radiotherapy treatment

24. Have you had reconstruction surgery?*

Yes
No

If yes, what type of reconstruction did you have?

25. Have you been diagnosed with lymphoedema?*

Yes
No

26. Have you had genetic testing?*

Yes
No

— If yes, what was the result of your genetic testing?

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

Part 3 – Other information

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

29. 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

Preferred phone number*

Please provide the best phone or mobile number to contact your referee on during business hours.

Email

Relationship to you*

Thank you for providing the above information to us. If you have any queries or concerns, please contact Kellie Holland, Team Leader Operations/Volunteer Coordinator on 03 8488 9834 or email [email protected]

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