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Volunteer Mentor Application

We invite you to share your experience with other patients by becoming a Peer Support Mentor. Please read through the entire application and complete all sections. Incomplete applications will not be considered.

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About You

If Yes:

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.

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. 

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