Wellspring Edmonton

SECTION ONE

1. Personal details

2. Please indicate the area(s) where you are interested in volunteering service

While Wellspring has a number of volunteer roles, we welcome volunteers with a diversity of skills and experience to help out with a variety of areas that may not be listed here. If you are interested in more than one area, please circle the role that most interests you. Please note that volunteers will be asked to provide us with an acceptable Police Record Check for several of the volunteer roles listed below.

3. Please indicate your availability

4. Have you volunteered for other organizations?

Yes No

If so, where and what were your roles and duties?

5. What special skills or experiences, education do you have that you feel would be helpful at Wellspring?

6. Spoken languages

7. What do you hope to gain through your volunteer experience at Wellspring?

8. Has cancer touched your life?

Yes No

9. Please explain further if you wish:

10. Please provide two (2) references: Do not include family members.

Wellspring Edmonton has my permission to contact the above references:
Yes No

11. I consent to having a Police Information Check, including Vulnerable Sector Search, as part of this application

Yes No

SECTION TWO: COMPLETE ONLY IF YOU ARE APPLYING TO BE AN ENERGY VOLUNTEER

1. All Energy Practitioners require appropriate Certification, Registration and Professional Liability Insurance.

Insurance Company:

2. Please indicate the certifications/qualifications you currently hold for Energy Therapies which you are interested in offering at Wellspring Edmonton volunteer sessions:

Reiki Therapeutic Touch Healing Touch Other

3. Are you currently employed as a practitioner in the above?

Yes No

4. From your perspective, what would your commitment to Wellspring look like?

5. How many sessions/hours would you do in a day? Or a week?

6. What are your goals related to the Energy Work you practice?

7. What in your experience can your Energy Work do for a person who is coping with cancer, bereavement, or care giving responsibilities?

Please read the following Code of Ethics and Confidentiality – indicate you are in agreement by signing.
If accepted at Wellspring Edmonton, I agree to the following:
1. I will not endorse or sell products, or services.
2. I will not promote myself or others for personal gain.
3. I will not provide any form of additional treatment information to the client.
All information learned from any client in Wellspring care will be kept in the strictest confidence and will only be shared, if appropriate, with Wellspring staff as necessary.

I accept these term and conditions

SECTION THREE: COMPLETE ONLY IF YOU ARE APPLYING TO VOLUNTEER IN THE EXERCISE PROGRAM

1. Education Level:

2. Certification:

CEP CPT

3. Other Training

4. Do you presently have Professional Liability Insurance?

5. Medical Oncology Knowledge – if so, please elaborate

6. Do you have experience in working with persons with cancer or other clinical populations (please specify)

7. Do you currently work as a trainer/practitioner?

8. From your perspective, what would your volunteer commitment at Wellspring look like?

9. Desired volunteer experience: ie: (room supervision, exercise class, individual trainer, assistant, other)

10. Are you interested in receiving advanced training specific to work with persons with cancer?

Yes No

Please read the following Code of Ethics and Confidentiality – indicate you are in agreement by signing.
If accepted at Wellspring Edmonton, I agree to the following:
1. I will not endorse or sell products, or services.
2. I will not promote myself or others for personal gain.
3. I will not provide any form of additional treatment information to the client.
All information learned from any client in Wellspring care will be kept in the strictest confidence and will only be shared, if appropriate, with Wellspring staff as necessary.

I accept these term and conditions