WellspringLogo volunteer application form
Date:
  (mm/dd/yy)
Name:
 
Address:
 
City:
 
Province:
 
Postal Code:
 
Home Phone:
  xxx-xxx-xxxx
Work Phone:
  xxx-xxx-xxxx
Fax:
  xxx-xxx-xxxx
Email:
 
Emergancy Contact:
  Name Phone xxx-xxx-xxxx
1.   Are you registered with Wellspring as a member? Yes No
2.   Please indicate the area(s) you are interested in helping with:
  Peer Support (must be a cancer patient or a caregiver of a cancer patient, and at least 18 years of age)
  Reception/Front Desk
  Energy Volunteer (Therapeutic Touch, Reiki or other Energy Therapy Practioner) (Please attach a copy of your training certificates and complete Section2)
  Support Group Co-facilitator (must be a cancer patient or a caregiver of a cancer patient, and have previously participated in a support group)
  Community Awareness (e.g. taking Wellspring display to special events; distributing Wellspring literature to hospitals)
  Fundraising
  Other, please specify

3.

 

Cancer Experience (if any)
Relation to person with cancer:
Self
Friend
Family Member: (name or relationship)
Other: (specify)

    Site/Type:
    How Long:
4.   Do you speak a second language? Yes No
    If Yes, which one(s):
    Would you be comfortable offering Peer Support in this language? Yes No
5.  

Which of the following days and times do you wish to volunteer? (check all that apply)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning
Afternoon
Evening
6.  

Have you volunteered for other organizations? If you have, briefly describe the duties you had.

 

7.  

Do you have special skills or experience that would be helpful as a Wellspring volunteer?

 

8.  

We recognize that people who volunteer their time do so for specific reasons. What do you hope to develop or gain through your experience at Wellspring?

 

9.  

Please provide us with the names of two references:

Name and Title
Phone Number
xxx-xxx-xxxx
Relationship to you and how long you have known this person

 

 

Section 2

If you are applying for an Energy Volunteer position (Reiki, Therapeutic Touch, Energy Therapy), please complete the following section
or scroll to the bottom of the form to submit:

Please note that Wellspring requires the following minimum qualifications:

Reiki 2nd Degree
Therapeutic Touch Recognized Practitioner
Energy Therapy Professional Studies Diploma
* plus a minimum of 20 treatments

   Please indicate the date you completed each of your qualifications:

Date Received (mm/dd/yy) Reiki Date Received (mm/dd/yy) Therapeutic Touch Other Energy Therapies (specify)
1st Degree Level 1
2nd Degree Level 2
3rd Degree Level 3
    Member of TTNO  
Approx. # of Treatments Approx. # of Treatments Approx. # of Treatments

 

    What other healing methods/courses have you been trained in that are incorporated into Energy treatments?

   

    What is your intention when administering a treatment?

   

    What, in your experience can your treatment do for a person who is coping with cancer, bereavement or caregiving responsibilities?

   

   If accepted as a volunteer at Wellspring, I agree to the following:

  • I will not endorse or sell products
  • I will not promote myself or others for personal gain
  • I will not provide additional information to the member regarding insights gained through their treatment
  • I will refer an individual requiring emotional support following an energy appointment to the peer support program for follow up.

 

Submission of this information is an acknowledgement that it is accurate and truthful in all respects.