MENTOR APPLICATION FORM
Name
*
First Name
Last Name
Gender
*
Female
Male
Non-Binary
Prefer not to say
Date of Birth (DD-MM-YYYY)
-
Month
-
Day
Year
Date
Student ID
*
Mobile
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you of Aboriginal or Torres Strait Islander origin?
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both
No
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Current Studies
Course currently completing
*
Current year of study
*
Campus location
*
Bedford Park
Tonsley
City Campus
Riverland
Online only
Other
About You
Cultural identity
Languages spoken
High School attended
*
Pathway to University
*
Australian Tertiary Admission Rank (ATAR)
Year 12 Grades Entry
UniTest
Foundation Studies
Assessment Centre Entry Pathway
Portfolio Entry Pathway
Internal/Higher Education transfer
Vocational Educational and training
STAT test
Other
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Screening
Do you have a current Working with Children Check (valid for 5 years)? If not, we will start one for you.
*
Yes
No
Do you have a current Responding to Risk of Harm Abuse and Neglect Certificate?
*
Yes
No
Which region is the most suitable for you to mentor? (select up to three)
*
SA - Southern Adelaide
SA - Northern Adelaide
SA - Western Adelaide
SA - Adelaide Hills
SA - Riverland
SA - Murray Bridge
SA - Fleurieu Peninsula
Online only
Becoming a Mentor
In 200 words or less, please tell us a little bit about yourself and why you want to be a mentor?
*
0/200
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Emergency Contact
Name of contact
First name
Last Name
Relationship to contact
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Where did you hear about us?
Please Select
Referral
Email
Lecture talk
Inspire Change website
Future Skills Award
Orientation Week
Career Hub
Submit
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