Mentor Registration Mentor Registration - Group Activities Mentor Registration - Group Activities This form is used to collect Mentor details for planned group activities Name * Name First First Last Last Address * Phone * Email Date of Birth * What is your preferred pronoun? he/him/his she/her/hers they/them/theirs sie/hir/hirs Other Are you Aboriginal and/or Torres Strait Islander? No Yes, Aboriginal Yes, Torres Strait Islander Yes, Aboriginal & Torres Strait Islander Prefer not to answer Do you speak any language other than English? Yes No If yes, which language(s)? Which of the following describe your situation? Retired Employed full-time Employed part-time or casually Self-employed Not currently employed If applicable, please provide your employment details below. Business name: Contact Person Contact Person First First Last Last Phone Email Your position title Brief description of your duties & activities: If applicable, briefly describe any current community work or volunteering activities: Please list any other relevant interests or area of expertise: Please list any relevant training or education: What are some favourite things you like to do with other people? What were your favourite subjects at school? What is one goal you have set for the future? Please tick all the activities from the list below which you are interested in Biking Science Music Gold Cooking Yabbying Reading Boating Sports Movies Computers Gaming Photography Gardening Travel The Arts Crafts Painting Animals Shopping Exercise Boardgames Fishing Swimming Landcare Anything we've missed for you, or would you like to elaborate? REFEREES: Please provide names and contact details of two referees. You will not be able to complete the application form unless you provide the name and phone number of at least one referee. Any information the MATES Mentoring Program gathers from these referees will be held as confidential and not released to you, the applicant. Please note: it will be the responsibility of the applicant to inform the referees listed that they will be participating in this personal reference check and will be contacted by the MATES Program Coordinator. Referee 1 Name * Referee 1 Name First First Last Last Referee 1 Phone * Referee 1 Email REFEREE 2 REFEREE 2 First First Last Last Referee 2 Phone Referee 2 Email WORKING WITH CHILDREN CHECK * I have a current Working With Children Check I agree to undertake a Working With Children Check It is mandatory for all MATES mentors, volunteers and staff of Wimmera Southern Mallee LLEN to have a current Working With Children Check. MEDIA CONSENT * Yes No I agree to allow the MATES Mentoring Program to use any photographic image, film or voice recording taken of me whilst participating in the mentoring program for promotional purposes. These images may be used by the school or the Wimmera Southern Mallee Local Learning and Employment Network (WSMLLEN) to promote the MATES Mentoring program through print, advertising, digital and social media. PRIVACY - WSMLLEN’s volunteer programs collect and administer a range of personal information for the purpose of operating the programs. It is committed to protecting the privacy of personal information it collects, holds and administers. WSMLLEN recognises the essential right of individuals to have their information administered in ways that they would reasonable expect – protected on one hand and accessible to them on the other. WSMLLEN is bound by Victorian privacy laws, the Information Privacy Act 2000 and other laws which impose specific obligations about handling information. We have adopted the principles contained in the Victorian privacy laws as minimum standards. In broad terms this means that WSMLLEN: Collects only information that is needed to effectively run the volunteer programs; Ensures that all program participants understand why we collect information and how it is administered; Use and disclose personal information only for our primary function or a directly related purpose, or for any other purpose only with the person’s explicit consent; Store personal information securely, protecting it from unauthorised access; Give participants access to their own information and the right to correct it. CHILD SAFE STATEMENT - Wimmera Southern Mallee LLEN is committed to promoting and protecting the interests and safety of children. We have zero tolerance for child abuse. Everyone working at Wimmera Southern Mallee LLEN is responsible for the care and protection of children and reporting information about child abuse. Child protection is a shared responsibility between the Wimmera Southern Mallee LLEN, all employees, workers, contractors, associates, volunteers and members of the Wimmera Southern Mallee LLEN community. The Wimmera Southern Mallee LLEN ‘Volunteer Child Safe and Duty of Care Policy’ helps to ensure that all parties are aware of their responsibilities for identifying possible occasions for child abuse and establishes controls and procedures for preventing such abuse and/or detecting such abuse when it occurs. DECLARATION * I declare that the information in this Mentor Application is, to the best of my knowledge, correct. I have read and understood the privacy and child safe statements. If you are human, leave this field blank. Submit
