Please complete this volunteer application if you are interested in serving as a Peer Partner volunteer. Once you complete the form, click the submit button at the bottom.


CONTACT INFORMATION:


EMERGENCY CONTACT INFORMATION:

If you are married/partnered, please indicate their name and contact information in Contact 1 section.



DEMOGRAPHIC INFORMATION:


MEDICAL INFORMATION:

If you are a caregiver, please provide medical information pertaining to the person you cared for.



PERSONAL STATEMENT I

What do you hope to gain from your experience as a peer volunteer through this program?



PERSONAL STATEMENT II:

Please briefly discuss why you would like to volunteer as a Peer Volunteer at Winship Cancer Institute. Additionally, please let us know your expectations as a Peer Volunteer.



LIABILITY STATEMENT:

Under the Health Insurance Portability and Accountability Act (HIPAA) law, we are required to have your signed consent to participate as a peer volunteer which includes, but is not limited to, your consent to share your personal contact information. By signing this form, you are providing consent for your personal information to be shared in the peer to peer program.


I give you permission to share my personal information which includes, but is not limited to, health information as well as contact information as a part of the Peer Partners program.


I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any liability now or in the future arising from my voluntary participation in and/or benefit from this peer support program.


I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any claims, demands and causes of action arising from my participation in and/or benefit from this peer support program.


I hereby affirm that I am over the age of eighteen (18) and I have read and fully understand the above and agree to be legally bound by it.