register YOUR INTEREST

Inspire Change

MENTOR APPLICATION FORM
Student ID*
FAN*
Name*

First NameLast Name
Gender*

Woman or FemaleMan or MaleNon-BinaryPrefer not to sayI/they use a different term (please specify below)Other
Do you identify as Aboriginal or Torres Strait Islander?*

YesNoPrefer Not to Say
Date of birth (DD-MM-YYYY)*

DayMonthYear
Date
University Email*
example@flinders.edu.au
Mobile number*

Area CodePhone Number
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cultural Identity
Languages spoken
Name of Degree/Course you are currently studying*
Pathway to University*

Year 12 resultsSTATTertiary transferFoundation Studies ProgramUniTestAssessment CentreYear 11 Grades Pathway
High School Attended*
Do you hold a current DCSI Working with Children Check? (If not we can start this process for you)

YesNo
Do you hold a current Responding to Risk Harm and Neglect Certificate? (If not we can send through the link on how to do this)

YesNo
Becoming a mentor
In 200 words or less, please tell us a little bit about yourself and why you want to be a mentor?*
Where did you hear about us?
Emergency contact
Name of contact
Relationship to contact
Mobile number

Area CodePhone Number
We will contact you to arrange an interview time. If you have any questions or concerns that require addressing before the interview, please email inspire@flinders.edu.au.
Should be Empty:

Inspire Change