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VOLUNTEER: Online Application

Fill the Gap, Inc.  Volunteer Peer Counselor Application Form

Peer Counselor volunteers are the heart of the Fill the Gap, Inc. telephone help line.  Your voice represents our program to our callers.

To begin the application process, please fill out this Peer Counselor Application Form to help us provide valuable services to those who may be facing a breast cancer diagnosis.

You can either submit the form online or fill it out, print and mail to:

Cynthia E. Cote, ARNP, Executive Director
Fill the Gap, Inc.
21 Littlehale Road
Durham, NH  03824

*Fields in RED are required

Name:
Address:
City: State: Zip:
Phone:
Home
 		 Work
Cell Other
Email:
Do you have internet access?  YES    NO

How did you hear about volunteering for Fill the Gap, Inc.? Hold down the control key to select more than one.

 
If applicable please tell us which one.

Why do you want to volunteer for this program?

All Peer Counselor volunteers must be breast cancer survivors.  Please share the following:

Year diagnosed:
Your breast cancer diagnosis:
Type of breast cancer:
Stage of breast cancer:
Are you still in active treatment? YES    NO
Treatment/Year: Chemotherapy
  Radiation
  Other surgeries
  Hormone Therapy
  Complementary Therapy
  Other
Relevant work or volunteer experience:

 

Volunteer Opportunities:
Hold down the CTRL key to make multiple selections
If you selected "Other" please explain:
  Your availability: Mornings
(6am – noon)		 Afternoons
(noon – 6 pm)		 Evenings
(6 pm – 12)		 Overnight
(12 – 6 am)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
References: Please pick references that are not relatives or friends such as clergy, coworkers, supervisors, or a volunteer coordinator you may have worked with in the past.  Your references will be contacted after your application interview is completed.
Reference #1: Note: This reference should be from a health care provider.
Name:
Email:
Telephone:
Relationship to you:
Reference #2:  
Name:
Email:
Telephone:
Relationship to you:
Reference #3:  
Name:
Email:
Telephone:
Relationship to you:

* You must enter the word   volunteer   in the box below to validate your application before selecting the submit button.

 

Thank you for your interest in Fill the Gap, Inc.!
In Partnership With:


 Fill The Gap, Inc.  *   21 Littlehale Rd.   *   Durham, NH 03824
Helpline: 877-FILLTHEGAP   *   Office: 603-570-3333   *   Email: info@fillthegap.info
© Copyright 2007.  All Rights Reserved.

Website design by Wendy McCoole.  Graphic design by Candace Perreault & Wendy McCoole.