Volunteer Location*
Select One Kennebunk, ME Scarborough, ME Topsham, ME Portsmouth, NH
About You
State*
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone Type*
Select One Cell Home Work
If Yes:
Employment Status*
Select One Student Looking for Employment Full Time Part Time Per Diem Retired Other
Why would you like to become a mentor?*
Previous Volunteer Experience (Please list location, dates and duties)*
Condition of Volunteer Service
You will be required to complete a background check. If you have a prior conviction: you may answer “No” only if your criminal record consists of one or more the following: (a) a sealed record on file with the Commission of Probation (b) Your case is a case where you were determined to be delinquent or to be a Child In Need of Services (CHINS), 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.
If yes, please provide details including date, location (city), nature of offense and disposition. Note: A conviction record will not necessarily be a bar to volunteer service.*
I certify that the statements made in this application are true, correct, and have been provided voluntarily. I understand that I will not be paid for my services as a peer mentor. 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 the practice to respect patient confidentiality and uphold the traditions and standards of New England Cancer Specialists. This includes abiding by the Smoke-Free Workplace policy, Agreement on Professional Behavior, and Substance Abuse and Intervention Agreement. I understand that as a Volunteer, I will be expected to demonstrate a readiness to help others, maintain health boundaries and assist patients through their cancer journey. I understand that my involvement in the peer mentor program will be contingent upon satisfactory results of a criminal and Department of Health & Human Services background check. The results of these reports will be treated as highly confidential.
Please make sure all questions marked with an “*” are answered before you save and close.
