Centers for Patients and Fa... - Add Volunteer Application

Volunteer Services Application

To apply for any volunteer position, we ask that you complete all sections. Please make sure you read through the entire application. Incomplete applications will not be considered. For PFAC please make sure to answer all REQUIRED fields.

Requirements to Volunteer

Please select the volunteer program you are interested in: *

Please select a location if you are applying to be a general volunteer *

Are you 18 or older?

Junior Volunteer Program (Due 3/15/2025)

Dana-Farber's Junior Summer Volunteer Program is a highly competitive program accepting a small number of high school students aged 16 to 18. The program runs from the second week in July through mid-August. Applicants must be able to commit to one 6-hour day a week (8am-2pm) for the full six weeks, and must also be available to attend or call in to a weekly meeting on Wednesday afternoons. Applications are due on March 15th, 2025. We will start rolling interviews at the end of March. Please note the Junior Volunteer Program will be available in the Longwood and Chestnut Hill campuses.

All applicants must have two professional reference forms submitted on their behalf. We recommend asking teachers, coaches, or similar adults to submit a reference. Family members should not submit references for an applicant. Please share the below link with the people submitting a reference for you.

Junior Volunteer Reference Form

Written Responses:

Can you commit to ONE FULL DAY A WEEK (8am-2pm) for a minimum of six weeks (Week of July 7th - Week of August 11th)

Yes
No
None of the above

The Junior Volunteer Program will be open in two locations, Longwood and Chestnut Hill. Please select which locations you are open to. Flexibility in location is appreciated.

Do you anticipate any breaks in commitment (I.e., vacations) that would prevent you from being onsite in Longwood during the six-week program?

Prompts for Video Application Submissions Please submit a video for each question. The video length can range from 30 seconds to 2 minutes for each question. Please upload a video for your response to each question to the link to the right. You must title your videos with your first name, last name, and the question you are answering (ex. Jessica_Gagnon_1). We are hoping to get to know your personality and what you would bring to the team!

Question 1: Why do you want to volunteer at Dana-Farber Cancer Institute, and what do you hope to learn?

Question 2: What would you, as an individual, bring to the community?

Question 3: How do you think the junior volunteer program might influence your life and/or your future career?

Click here to Submit Videos

Optional: Is there anything you think is important to share that we did not ask you about?

Summer Volunteer Program

If you are interested in volunteering at Dana-Farber Cancer Institute during the summer, please be advised of the following requirements: Volunteers must serve two half days (four hours each) or one full day (eight hours each) per week for a minimum of 10 consecutive weeks, totaling 80 hours of service. Once potential volunteers have completed the Summer Application Form, they will be contacted in early May to schedule an interview and continue with the application process. Applications are due the first Friday of April.

Can you commit to two half days (four hours each) or one full day (eight hours each) per week for a minimum of 10 consecutive weeks, totaling 80 hours of service?

Please tell us why you want to volunteer at Dana-Farber? Be specific as possible and include:
Characteristics and skills that you posses that would benefit the Institute;
What placement is of interest to you and why

How long do you anticipate being able to volunteer at Dana-Farber? Please describe any breaks in your commitment.

General Information

Instructions: Please fill out the application below as completely and fully as you can.

We ask that patients be one year out of active treatment before applying to be a volunteer. However, the One-to-One Program and PairWISE Program requires applicants to be at least one year out of initial diagnosis before applying to be a peer mentor. The SoulMates program requires early-stage applicants to be at least two years out of active treatment and applicants living with metastatic breast cancer to be at least one year out of metastatic diagnosis before applying to be a volunteer mentor.

First Name

Last Name

Preferred Name

Date of Birth

Gender identity (optional)

Preferred Pronouns

Preferred Phone Number

ext.

Address

Phone Type

E-mail Address

Fluent Languages

Race and/or Ethnicity (optional)

Religion (optional)

Education/ Work Experience

Highest Level of Education

School Name

School City

School State

Have you ever applied to or been employed by DFCI, either as staff or a volunteer?

If yes, please indicate Department:

Dates:

Position:

Supervisor:

Employment Status

Occupation

Employer

Volunteer Organization

Previous Volunteer Position

Duties

PairWise: Parent Peer Mentor Program

PairWISE administrators use the following information to match you with caregivers who have similar circumstances as you. Not all circumstances may be directly related to your child s cancer experience. Some caregivers may also have concerns about other children, work, relationships, finances, lifestyle, etc. which they may perceive as being impacted or having an impact on their experience of their child s cancer diagnosis and treatment. For example, did you deal with questions and concerns around any of the following: speaking with young children about the diagnosis, balancing work and family commitments during treatment, giving birth or adopting another child during treatment, divorce, etc.? If you feel comfortable sharing these parts of your own experience, please answer to the best of your ability and elaborate as much as possible. The broader the range of information you provide, the greater the number of patients/family members who may identify with you. We ask that your child is at least 1-year from the end of treatment before you can begin taking on caregivers as a new mentor. However, you can apply to be a mentor before that 1-year point if you choose.

Patient Information

Child's Full Name

Was your child ever treated anywhere other than DFCI/BCH?

Gender/Preferred pronouns (optional)

Child's age when diagnosed, Childs age now

Diagnosis Type

Date of Diagnosis

What treatments did your child receive?

Is your child still in active treatment? If yes, please provide the anticipated end date (month/year). If no, please indicate the month/year when treatment ended or when your child passed away, if applicable.

If your child has/had a metastatic disease, where are/were the metastases? (optional)

If your child has/had a recurrence, what was the date of the recurrence? (optional)

Who is/was your childs oncologist?

Who is/was your family's social worker or psychologist?

Additional Information regarding your child's diagnosis that you feel would be helpful for us to know (optional)

Household Information

Your Relationship Status at time of Diagnosis

Your relationship status currently

Are there other children/family members/loved ones in the home?

Did you work during your child's treatment?

Check which additional services you received.

What do you and your family do for fun?

What are some self care activities you practice?

Joining our Program

How did you hear about this program?

Why are you interested in being a pediatric caregiver mentor at this time?

Describe what type of caregiver or family you think you would be most helpful to?

Anything else you would like us to know about you, your family or your experience?

Connection Logistics

Can you make a one year commitment to mentoring?

I have access to the following technology and I am comfortable with connecting with a caregiver once matched using the following:

Volunteer Opportunity

The following are the requirements to be a volunteer at Dana-Farber:
1.Commit to at least one four-hour shift each week for one year
2.Be at least 18 years of age

We will review your application to determine eligibility for a placement, and then email you for an interview with the Senior Manager of Volunteer Services. We select volunteers for placement based on availability, time commitment, interest, and skills.

Please select your top 3 preferred roles.

Please tell us why you want to volunteer at Dana-Farber: Characteristics and skills you posses that would benefit Dana-Farber
Whether you have worked with patients and families before, and what you found rewarding and challenging

Is there anything you would not want to be a part of?

How long do you anticipate being able to volunteer at Dana-Farber?

Days Available

Please specify hours available each day you've selected.
(Example shifts: 7-10am, 10am-1pm, 11am-2pm) We do not have evening or weekend shifts available.

One-to-One

Information for Mentor Profile

One-to-One uses the following information to match you with patients/family members with similar circumstances. Not all circumstances may be directly related to your cancer experience. Some patients may also have concerns about children, work, relationships, finances, lifestyle, etc. which they may perceive as being impacted or having an impact on their cancer experience. For example, did you deal with questions and concerns around any of the following: speaking with young children, fertility, running a business during treatment, talking with your boss, divorce, etc? If you feel comfortable sharing these parts of your own experience, please answer the questions to the best of your ability and elaborate as much as possible. The more broad the range of information you provide, the greater the number of patients/family members who may identify with you.

Are you or your loved one in treatment?

Where did you or your loved one receive treatment?

Marital / Partnership Status at Time of Diagnosis

Current Marital / Partnership Status

Ages of Children at the Time of Diagnosis

Describe what type of patient or caregiver you feel you would be most helpful to:

Care Team

Who is / was your oncologist?

Who is / was your nurse?

Who is / was your social worker?

Care Team Reference

To become a volunteer, you must have a referral from a member of your medical team. Please provide the name and contact information for the medical provider who would be best able to serve as a reference for your application to this program.

Name:

Title:

Phone Number:

ext.

Email:

Patient Diagnosis & Treatment

Diagnosis

Date of Diagnosis

If you have any preexisting conditions, please share here:

Stage

Location (if applicable)

If you had a metastatic disease where was/are the metastases?

If you had a recurrence, what was the date of your recurrence?

What treatments did you receive?

Additional information regarding your diagnosis and treatment:

If you are a Caregiver Applying

In order to assure compliance with the Federal HIPAA regulations, family members must include the patient's name and obtain his/her signature to indicate that they understand you may use their name and/or medical history information in your capacity as One-to-One members. Please download and submit the attachment with your application to obtain formal consent from patient and/or legal guardian.

Download and Sign: One to One Consent Form

Upload Consent Form Here

Profile and Interest in PFAC (REQUIRED)

Which council are you applying for? Adult or Pedi?

Are you a patient or caregiver? Select all that apply.

What year was the patient diagnosed?

What type of cancer, blood disease, or other?

What did treatment involve?

What is the current status of the patient? Select which option best defines the status.

Areas of interest for PFAC (select all that apply)

What skills or experience would you bring to PFAC?

Attachments (REQUIRED)

Please write an interest statement including, but not limited to, the following information:
1. Why are you interested in PFAC membership?

2. What does patient advocacy mean to you?

3. Why do you believe you will be an advocate for patient-and-family-centered care?

4. Why does diversity and inclusion matter to you?
5. What is the amount of time you are able to dedicate to PFAC volunteer work?

Interest Statement (REQUIRED)

Resume (REQUIRED)

If You are a Caregiver Applying for PFAC

In order to assure compliance with the Federal HIPAA regulations, family members must include the patient's name and obtain his/her signature to indicate that they understand you may use their name and/or medical history information in your capacity as PFAC members. If the patient is a minor and the family member is not the legal guardian, the applicant must obtain the signature of the minor's legal guardian.

Download Consent Form Here

Upload Consent Form Here:

References

To become a volunteer, you must provide at least one reference. Students should list an advisory or faculty member for one of the references. No relatives.

Name

Relationship

Company/ Institution

Phone Number

ext.

Email Address

Soulmates

Diagnosis and Treatment

Diagnosis Type (IDC, ILC, IBC, DCIS, metastatic, Etc.)

ER/PR/HER-2 Status

BRCA or other genetic marker status

Stage (0-IV)

Date of Diagnosis

Age at initial diagnosis, metastatic if applicable

Treatment Regimen

Have you had reconstruction surgeries?

Treatment Providers/Care Team Member (optional)

Do we have authorization to contact your medical team?

Were you treated anywhere other than DFCI/BWCC?

If yes, please list where and for which treatments?

Is there anything else you'd like us to know about your treatment or cancer experience? (i.e., lymphedema, IVF, pregnancies, recurrences, metastatic diagnoses)

Family

Your relationship status at time of initial diagnosis, metastatic if applicable (optional):

Your Relationship Status Currently (optional):

Children

Child(ren) s age(s) at initial diagnosis, metastatic if applicable:

Current Ages of Children:

Are there other children/family members/loved ones in the home? If yes, please indicate who, and include ages of any children/siblings at the time of the patient s diagnosis and their ages now. (optional)

Availability

Can you make a one year commitment?

Are you able/willing to attend monthly virtual meetings? (Mentor meetings and/or SoulMates Community meetings)

I have access to the following technology and am comfortable connecting using the following:

Did/Do you work during your treatment? (optional)

What do you and your family enjoy doing for fun? (optional)

What are some self-care activities you practice? (optional)

How did you hear about this program? (required)

Why are you interested in being a breast cancer mentor at this time? (required)

Anything else you would like us to know about you, your family, or your experiences?

Condition of Volunteer Service

Conditions of Volunteer Service (Please read before signing): Prior Convictions (Please read this carefully before answering) You may answer �NO� only if your criminal record consists of one or more of the following: (a) a sealed record on file with the commissioner of Probation, (b) Your case is a case where you were determined to be delinquent or to be a child in need of services, which did not result in a complaint transferred to Superior Court for criminal prosecution, or (c) your crimes were misdemeanors and they occurred five or more years ago. Note: A conviction record will not necessarily be a bar to volunteer service.

Have you been convicted of a felony or misdemeanor? *

If yes, give details including date, location (city), nature and offense and disposition.

I certify that the statements made in the volunteer application are true and correct, and have been given voluntarily. I understand that I will not be paid for my services as a volunteer. I further understand that I may be asked to discontinue my volunteer services at any time for any reason. I agree to abide by the guidelines of Volunteer Services, to respect patient confidentiality, and uphold the traditions and standards of Dana-Farber Cancer Institute, including abiding the Smoke-Free Workplace Policies, Agreement on Professional Behavior, Substance Abuse Policy and Invention Agreement. Volunteers will demonstrate a readiness to help others, maintain healthy boundaries and assist patients through their cancer journey. I understand that volunteer service will be contingent upon approval from the Volunteer Services and Occupational Health Departments. Volunteer service is also contingent upon satisfactory results of a background check, including a criminal record check. The results of the checks will be treated as highly confidential.

I agree/ Provide Consent to Store My Information *

Please make sure all questions are answered before you save and close.

Applicant Signature *

Date

06-05-2025

Admin

Status

Role

Notes

Orientation Date

One-to-One Status

Profiles

Add Profile

Field label
Column heading override
Justification
What does auto mean?

For which table?

Add Volunteer Application

Can I annotate fields to indicate their intended use?

Client Performance Report

To Paste

Quickbase will send a report of the events currently displayed on your calendar.
Email addresses

Editing Conflict
you changed ' ' from: to:	changed ' ' from: to:

To Paste
To paste clipboard data that comes from another program right-click on the text area below, select Paste, then click OK.