Mentoring application form – Odyssey Victoria

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Applicant details

Name *

First

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation

Place of work

Date of birth *

Gender

Do you identify as Aboriginal or Torres Strait Islander?

Yes
No
Prefer not to say

Do you identify as part of the LGBTQIA+ community

Yes
No
Prefer not to say

Country of birth

Language/s spoken

Please list the languages you are able to speak.

Drivers license number

Expiry date

How did you hear about the Odyssey Victoria Mentoring Program?

Word of mouth
LinkedIn / Probono
Website
Social media
Other

If other, please specify.

Medical conditions

Do you have any medical conditions and/or related medications that may impact on your ability to perform your role? If so, please provide details.

Emergency contact details

Name *

First

Last

Phone

Relationship to applicant

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Application questions

Why are you interested in becoming a mentor? Why now?

How would you describe the role of a mentor?

What do you believe are some of the key principles or values to uphold when working with people who are leaving drug and alcohol rehabilitation?

What personal qualities, strengths, attributes or skills would you bring to the mentoring relationship?

Are you currently employed, if so, what is your job? If not – what work experience do you have?

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Application questions (continued)

What are your hobbies/interests?

Have you held other volunteer roles in the past? Please also list any community groups/organisations to which you belong or are involved with.

Do you have a history of substance use?

Please note this does not automatically exclude you from being a mentor. People with a lived experience will be strongly considered but must have at least five years in recovery.

When are you available to meet with your mentee?

eg. Saturday morning, weekday evenings.

Would you be interested in mentoring a parent with young children?

Is there anything else that we should know about you that would help us with assessing your application?

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Referees

Referee 1

Name *

First

Last

Phone

Email *

Relationship to applicant

Referee 2

Name *

First

Last

Phone

Email *

Relationship to applicant

what a Medical

Declaration

Confirmation *

I confirm that I wish to apply for the position of Leavers Mentor and that the information provided above is correct. I understand that if my application is successful, I will be required to provide a current Police Check, Working with Children Check and complete Odyssey Victoria Mentor Induction Volunteer Paperwork.

Date *

Signature

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