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IDEGM-HR-09NameVolunteer & Therapist Application Form
Revision2Approved ByJacqueline Daly
Approved Date01/03/2021Review Date2023

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)