Mentor Form


Date of Birth:

Cultural Background:

Do you fluently speak any other languages other than English?:

If Yes, what languages?:

Do you hold a current Drivers Licence?:

Do you have access to a vehicle?:

Current employment status:

Do you have any circumstances that may impact on your ability to act as a mentor?:

If yes, please specify:

I am a Australian citizen or permanent resident:

Please list any previous volunteer you have done:

How did you hear about WJN's Mentoring Program?:

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?:

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?:

Are you willing to abide by a Mentoring Code of Conduct?:

Can you commit to 12month participation in WJN's Mentoring Program?:

Do you agree to participate in 2 day training?:

Do you agree to attend on-going training and supervision every 6 weeks?:

Please supply email contacts for 2 referees:

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

Article by: wjn