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Peer Support Application

Care for Caregiver (C4C) Program

Name *

First Name

First Name

Last Name

Last Name

Employee Number *

Department Name *

Position *

Shift *

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Other *

Manager or Department Head *

First Name

First Name

Last Name

Last Name

Manager or Department Head Email *

Peer Support Applicant

Why would you like to be a Peer Support Team Member? (5-6 sentences)

Why would you like to be on the C4C Peer Support Team? (5-6 sentences) *

What strengths would you bring to this role? *

Give an example of a time you helped someone through a difficult situation at work? *

How did you learn about the Care for the Caregiver Peer Support Team? (Select all that apply) *

Co-worker

Manager/Supervisor/Educator

Staff meeting

Flyer

News of the Week email

Computer screen saver

Recruitment booth outside at shift change

Care Cart rounds

Stress First-aid Station

Other

Other (please describe) *

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