Personal Details

First Name *

Last Name *

Date of birth *

Phone *

Email *

City

How did you hear about us?

About you

Tell us about yourself, your interests, hobbies, education etc. *

What is your chosen profession? Briefly explain why you have chosen this. *

What jobs, experiences, qualities, skills, or other attributes do you feel you have that would specifically benefit a young person? Please explain. *

Have you ever lived in rural, regional or remote Australia? *

Yes

Do you know anyone currently participating in the program? If so, who?

If you know a mentor who is currently participating in the program we will endeavour to ensure you are matched to the same school.

Clearance Details

Wheatbelt & Beyond Youth Mentoring requires all mentors to have a current Working With Children's Check and Police Clearance in accordance with our child protection policy. If you do not currently have these clearances we will assist you to apply for them once your application has been submitted.

Do you currently have a Working With Children's Check? *

Yes

Working with Children's Check

Don't have it on you right now? Upload it later on!

Do you have a current Police Clearance?

Yes

Please upload a copy of your Police Clearance

Don't have a copy right now? That's okay, upload it later!

References

All mentor applicants are subject to a referee check prior to being accepted into the program. Please list three people, at least one being a professional colleague, as character witnesses (people you have known for at least one year).

Name
Phone Number
Relationship to you

Name
Phone
Relationship to you

Name
Phone
Relationship to you

Emergency Contact Details

Please provide the details for at least one emergency contact. For your safety, it is especially important that you update these details prior to travelling to a rural community.

Emergency Contact Name *

Emergency Contact Number *

I understand that Wheatbelt & Beyond Youth Mentoring is not obliged to provide a reason for their decision in accepting or rejecting me as a mentor.

I agree to the Terms and Conditions of the program and declare that the information in this application is true and correct.

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