Volunteer Application

Profile Information

First Name

Last Name

Date of Birth

Contact Information

Country

Address

Apt/Ste

City

State

Zip Code

County

Phone Number

One phone number is required.

My Information

My Gender

I am a...

Cancer Survivor

Family member / caregiver

Both

Cancer Type. If your cancer type is not listed, choose Other.

Date of diagnosis. Approximate date is acceptable.

Stage of Cancer

Cancer Treatment. Select all that apply. If your treatment is not listed, choose Other.

Are you or your loved one still receiving treatment?

I am comfortable discussing the following (choose all that apply):

Metastasis location

Tell us about the challenges you faced. For survivors: what challenges did you experience as the result of your treatment (lymphedema, loss of taste, types of complications from reconstruction, changes in independence, changes in family life, etc.)? For caregivers: what challenges did you experience as the result of caring for a loved one during his/her treatment?

Care receiver Information

The care receiver is my

Age of Care Receiver at Diagnosis

The care receiver's gender is

Did your care receiver survive?

Cancer Type. If your cancer type is not listed, choose Other.

Date of diagnosis. Approximate date is acceptable.

Stage of Cancer

Cancer Treatment. Select all that apply. If your treatment is not listed, choose Other.

Are you or your loved one still receiving treatment?

Metastasis location

Other Information

If you prefer in-person training, please select the appropriate city.

Have you ever been matched with a CanCare volunteer?

How did you hear about this volunteer opportunity?

Marital Status

Spouse/partner First Name

Spouse/partner Last Name

Languages in which you are fluent

Please list all the years your children were born

What is the quickest way to reach you during business hours?

If you or your loved one had a recurrence, what stage was the recurrence?

Primary Cancer Physician

With which hospital is this doctor affiliated?

Where did you or your care receiver have treatment?

Are you interested in offering support in-person at area hospitals/treatment centers?

Place of employment

Occupation

At the time of diagnosis, what was your employment status?

Do you have experience in the following areas? If so, please select the areas you are interested in volunteering your skills

Religious Affiliation and/or Place of Worship

Reason for volunteering

Emergency Contact

First Name

Last Name

Phone Number

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