register YOUR INTEREST

Inspire Change

MENTOR APPLICATION FORM
Student ID *
FAN *
Name *

First Name Last Name
Gender *

Woman or Female Man or Male Non-Binary Prefer not to say I/they use a different term (please specify below)
Do you identify as Aboriginal or Torres Strait Islander? *

Yes No Prefer Not to Say
Date of birth (DD-MM-YYYY) *

Day Month Year
Date
Email *
example@example.com
Mobile number *

Area Code Phone Number
Residential Address *

Street Address

Street Address Line 2

City State / Province

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

Year 12 results STAT Tertiary transfer Foundation Studies Program UniTest Assessment Centre Year 11 Grades Pathway
High School Attended
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 Code Phone 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.
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