Mentoring Expression of Interest form

Youth Mentoring

To register your interest to become a youth mentor please complete the below information.

All personal information provided to the Sammy D Foundation is confidential and only used for mentoring and/or statistical purposes.

Question Title

* 1. Family name:

Question Title

* 2. Given name(s):

Question Title

* 3. DOB:

Date

Question Title

* 4. Age:

Question Title

* 5. Cultural Background:

Question Title

* 6. Sex:

Male

Female

Prefer not to say

Other (specify if comfortable)

Question Title

* 7. Address

Street Address:

Suburb:

Post code:

Question Title

* 8. Phone number:

Question Title

* 9. Email address:

Question Title

* 10. Willing to use own transport?

Yes

Question Title

* 11. Emergency contact information

Name:

Relationship:

Phone number:

Question Title

* 12. Current employment status

Student

Seeking paid work

Part-time

Full-time

Casual

Retired

Question Title

* 13. Education/qualifications/relevant training:

Question Title

* 14. Why are you interested in becoming a mentor?

Child Protection Statement

Question Title

* 15. Children and young people who are involved in our activities should receive the highest possible standard of care and protection.
Therefore, in all our work, we seek to ensure the well-being and development of each child and young person. Within this context, the person named on this registration is committed to the protection of children and young people from all forms of abuse.
Have you been interviewed, questioned or charged by Police in relation to any offence involving children, young people, violence, alcohol or drugs?

Yes

Question Title

* 16. Have you been convicted of any offence involving children, young people, violence, alcohol or drugs?

Yes

Question Title

* 17. If ‘yes’ for either question, please give details. You may choose to discuss this in confidence with the Volunteer Coordinator (please advise if this is how you would like to proceed).

Question Title

* 18. How did you hear about the Sammy D Foundation mentoring program?

Authorization

Question Title

* 19. I confirm that the information contained in this application is true and correct. I authorize the Sammy D Foundation to keep electronic and hard-copy records of my information.

Yes