Apply to be a mentor

Personal Information

Family Name
Given Name/s
Preferred Name
Student ID#:
Email address:
(Regularly used)
Home Phone:
Mobile:
Please specify best contact number:*
Home Phone Mobile

Postal address:
City/Suburb:
State:
Postcode:

Please indicate T-shirt size: S M L XL

Academic Details

Your primary Faculty/ School (at uni):
Your degree program:
Current year of study:
Expected graduation date:
Name of school attended in year 12:

Academic Results

Previous year Semester 2

Number of courses undertaken:
Number of courses with pass or above:
Number of courses failed:
Number of courses incomplete/withdrawn:

Current year Semester 1

Number of courses undertaken:
Number of courses with pass or above:
Number of courses failed:
Number of courses incomplete/withdrawn:

Educational Highlights/ Awards:

Current employment/anticipated employment 2011

Mentoring Details

Have you been a mentee? Yes    No

If yes, Year/ Program Name:

Have you been a mentor? Yes    No

If yes, Year/ Program Name:

Do you plan to apply for or have you been accepted into any other University networking program?

If yes, Year/ Program Name:

Are you an Aboriginal or Torres Straight Islander? Yes    No

If yes, are you willing to mentor non-Aboriginal or Torres Straight Islander students? Yes    No

Why would you like to become a mentor/ continue to be a mentor?