CholangioConnect Mentoring Signup Form - Cholangiocarcinoma Foundation

Thank you for completing this application form and for your interest in volunteering with us. It is the policy of the Cholangiocarcinoma Foundation to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

I'd like to be a

Patient Mentor
Caregiver Mentor

About You

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone (Home)

Phone (Mobile)

Email*

Please select your relationship with cholangiocarinoma:*

Patient (personally diagnosed with cholangiocarcinoma)
Care-Giver (cared for a family member or friend diagnosed with cholangiocarinoma)

Education

Last School/University Attended

Course of Study

Highest Level Completed

Employment

Employer

Position

Duties

Date Started

MM

DD

YYYY

Date Ended

MM

DD

YYYY

Supervisor

Supervisor Phone

Supervisor Email

Availability (number of hours per week for volunteering)

Skills, Knowledge, Abilities, Interests

Thank you for your interest in becoming a CholangioConnect Mentor.

Here is what you can expect as you move forward in this process to become a volunteer mentor. In this important role, you will inspire hope and offer cholangiocarcinoma patients or caregivers the opportunity to ask questions and receive much-needed support from someone familiar with this disease.

Step #1 – complete online application for all CCF volunteers [10-15 min] (this form)

Step #2 – the CCF Volunteer Coordinator, Cindy Thomas will contact you to schedule a call to discuss your application

Step #3 – sign and return the Volunteer Confidentiality Agreement [3-5 minutes]

Step #4 – complete online volunteer training [at your own pace]

Step #5 - complete the CholangioConnect online questionnaire for mentors [5-10 minutes]

Step #6 – the CholangioConnect Program Coordinator, Patty Maxin will contact you to discuss mentoring opportunities

Step #7 – Patty will “match” you with patients/caregivers who have requested a mentor

Step #8 – begin mentoring!

How did you hear about the CCF Volunteer Program?

Other

Emergency Contact

Name

First Last

Relationship

Phone

References

List two people, not related to you who can provide references on your ability to perform this volunteer position

Reference #1 Name

First Last

Relationship

Phone

Email

Reference #2 Name

First Last

Relationship

Phone

Email

Agreement

*

I understand that this is an application for and not a commitment or promise of volunteer opportunity.

*

I certify that my answers on this application are true and complete to the best of my knowledge.

*

I certify that I have not withheld any information that would unfavorably affect my application for a volunteer position.

*

I understand that information contained on my application will be verified by CCF.

*

I understand that misrepresentation or omission of facts on this application may be cause for rejection of this application or dismissal as a volunteer.

Confidentiality Agreement

I understand that volunteers of the CCF have an ethical and legal obligation to respect the privacy of all stakeholders including board of directors, staff, volunteers, and members of the patient and medical communities.

This agreement applies to all volunteers associated with and/or involved in the activities or affairs of CCF:

I understand that I may be given access to confidential and/or proprietary information to the extent necessary in order to perform my duties as a volunteer with the CCF.

I shall not, at any time either during or subsequent to this participation with CCF make unauthorized disclosures or unauthorized use of any information that is considered to be proprietary or confidential by the CCF except where required for an authorized business purpose. Proprietary information includes, but is not limited to, all information, documents, notes, files, records, computer files or similar materials whether in written, oral or electronic form. This includes information protected under any applicable state or federal privacy laws.

I shall not disclose any information obtained in the course of my volunteer placement to any third parties without prior written consent from the organization. This includes but is not limited to information pertaining to financial status and operations such as budget information, donations of money or gifts in kind, salary, or information pertaining to patients, staff or other volunteers.

If I am unsure about the confidential nature of specific information, or whether specific information may be protected under state or federal law, I will ask the staff member supervising my actions for clarification before disclosing the information.

When I cease my participation as a volunteer with the CCF, I will return all CCF-related information and property that I have in my possession, including but not limited to documents, files, records, manuals, information stored on a personal computer, cell phone, and equipment or office supplies.

Failure to comply with the confidentially policies of the organization may result in disciplinary actions, including the dismissal of the volunteer.

*

I understand the above and agree to uphold the confidentiality of these matters both during and following my volunteer service with the organization.

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