OT Mentorship Application Form

OT Mentorship Application Form

6 or 12 Month Mentorship Program
Applications for our 6 and 12 month programs will close on Tuesday 6th October 2020.

Following that, the leaders of our qualified and active Occupational Therapy team will assess each application and will be in touch if you are successful in gaining one of the limited positions.
Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Program Preference

6 months12 months
Private Email
yourname@gmail.com
University Email
If still in use: yourname@mymail.unisa.edu.au
University Attended
e.g Flinders University
Date University Commenced
Date University Completed (or expected end date)
Course Completed
e.g B.App.Sc.OT
Clinical Placements

In your final year at University
Clinical Placement Organisation #1
e.g Barkuma
Clinical Placement #1 Dates
Clinical Placement Organisation #2
e.g Barkuma
Clinical Placement #2 Dates
Volunteer Experience

If Applicable
Organisation #1
e.g Barkuma
Volunteer dates
Duties
e.g Support Work
Organisation #2
e.g Barkuma
Volunteer dates
Duties
e.g Support Work
Employment

Current and Future Plans
Current Workplace
Hours per week
e.g 15 hrs casual
Duties
e.g Support Work
If you have secured future employment, please detail where and your expected role:
Please detail 3 of your personal goals for the next 12 months
Please detail 3 of your professional goals for the next 12 months
Mentor Criteria – is there anything you are looking for in a mentor?
e.g gender preference, experience
Areas of Occupational Therapy that interest you the most:

PaediatricsMental HealthRehabilitation/Assistive TechnologyCommunity HealthAcute CareAged Care
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Relationship to Emergency Contact
Please provide any other details you feel may assist your application for our Mentorship program.
Signature*

Clear
Please upload a 30 second video talking about why you chose to study Occupational Therapy.

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OT Mentorship Application Form

Clinical Placements

Volunteer Experience

Employment