Mentor Form

First Name

Last Name

Address

Zip

City

State/Province–None–Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia

Occupation:

Phone

Email

Date of Birth:

Cultural Background:–None–AustralianAboriginal and Torres Strait IslanderPacific IslanderVietnameseOther

Do you fluently speak any other languages other than English?:–None–YesNo

If Yes, what languages?:

Do you hold a current Drivers Licence?:–None–YesNo

Do you have access to a vehicle?:–None–YesNo

Current employment status:–None–F/TP/TStudentHome DutiesRetiredUnemployed

Do you have any circumstances that may impact on your ability to act as a mentor?:–None–YesNo

If yes, please specify:

I am a Australian citizen or permanent resident:–None–YesNo

Please list any previous volunteer you have done:

How did you hear about WJN's Mentoring Program?:–None–Word-of-mouthOnlineSocial MediaRecruitment AdOther

Other, please state:

Why are you interested in becoming a mentor with WJN?:

What personal qualities or life experience can you bring to WJN's Mentoring Project?:

Do you have any connections, either personal or professional, with the Criminal Justice System?:–None–YesNo

If yes, please provide details. Please note, answering yes to will not affect your eligibility to become a WJN mentor:

Are you willing to enter into and sign a Mentoring Agreement?:–None–YesNo

Are you willing to abide by a Mentoring Code of Conduct?:–None–YesNo

Can you commit to 12month participation in WJN's Mentoring Program?:–None–YesNo

Do you agree to participate in 2 day training?:–None–YesNo

Do you agree to attend on-going training and supervision every 6 weeks?:–None–YesNo

Please supply email contacts for 2 referees:

As Jenny's mentor how do you think you could best support her?: