Volunteer Services
Application for Community Ambassador Volunteer Position
Instructions: Volunteer service at DFCI is a commitment to our patients and staff. Please fully complete the application below. The information you provide will help us determine your motivation to volunteer as well as your skills, abilities and availability. We will not consider incomplete applications for volunteer service. Please submit your completed application for the Community Ambassador Program to Magnolia Contreras, Director of Community Benefits, at . Please note that this application form is only for the Community Ambassador Volunteer Position at DFCI.
Personal (Please Print)
Name
Address City State Zip Code
Home # Work #______Cell # ______E-mail address: ______
Are you 18 years or older? Yes No
Have you worked or volunteered at Dana-Farber in the past? Yes No
Dates Employed/Volunteered ___/___/___ to ___/___/___
Position______Department______
Supervisor______Reason for leaving______
Availability: Volunteer shifts will typically occur between 8:30 am to 5:00 pm, Monday – Friday, but occasionally evening or weekend availability may be requested for certain events as needed. Please note your availability below:
Monday ______to ______Tuesday ______to ______Wednesday ______to ______Thursday ______to ______Friday ______to ______Saturday/Sunday ______to ______
How long do you anticipate being able to volunteer at Dana-Farber? Please describe any breaks in commitment. Please note that we require a minimum commitment of at least six to twelve months in accordance with the time commitment expectations described in the Community Ambassador Volunteer Service Description.
______
______
______
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Education
Are you currently enrolled in school? Yes □ No □
High School______State______Month/year of graduation______
College______date/expected date of graduation______
Area of Study______
Employment
Are you currently employed? Yes □ No □
1. Current or most recent employer ______From______To______
Position held ______Supervisor______
Supervisor phone number:______City,State______
2. Previous employer______From______To______
Position held ______Supervisor______
Supervisor phone number:______City,State______
Reason for leaving ______
References
No relatives please. Students should list an advisory or faculty member as one of the references.
1.Name______Relationship______
Company/Institution______Email______
Address______City______State_____Zip______
2.Name______Relationship______
Company/Institution______Email______
Address______City______State_____Zip______
Volunteer Experience
Please list and describe in detail any volunteer position(s) you currently hold or previously held. Please include duties completed and amount of time spent at the position.
1.Most recent position______From______To______
Agency or affiliation______
Duties completed ______
2.Volunteer position______From______To______
Agency or affiliation______
Duties completed ______
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Motivations to Volunteer
Please tell us why you want to volunteer at Dana-Farber? Be specific as possible and include: 1) Characteristics and skills you possess that would allow you to be effective in serving the Institute and community residents as a Community Ambassador; and 2) Why the role of Community Ambassador is of interest to you.______
______
______
______
______
______
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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? Yes □ No □
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 to uphold the traditions and standards of Dana-Farber Cancer Institute, including abiding by the Smoke-Free Workplace Policies. 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 Volunteer Service 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.
Applicant’s Signature Date
THIS SECTION IS FOR OFFICE USE ONLY
CommentsDate of Interview Initials
Volunteer Badge Volunteer ID Number
Service Area Position
Day Shift Supervisor
OHS Date Orient Date Start Date Evaluation Y N
Reference Source Non-Student Student
Parking Card # Number of times per week Junior Volunteer
Application Received: ______
CORI Faxed Sent references Confirmation letter
Notification to supervisor Meet with supervisor Confirmed Y N
Approved for Volunteer Service Yes No
Signed Date