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[null,null,"MENTORSHIP APPLICATION FORM\nInter- generational mentorship programme  \n"]
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[null,null,"CONTACT INFORMATION"]
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[null,null,"Name"]
[null,"*","Age"]
[null,null,"Date of birth"]
[null,"*","Address"]
[null,null,"Home Phone"]
[null,null,"Work Phone"]
[null,null,"Email"]
[null,null,"Twitter/Facebook ID (if applicable)"]
[null,"*","What is the best way to contact you?"]
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[null,null,"EDUCATION INFORMATION"]
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[null,"*","What is the higest form of education you have completed?"]
[null,"*","Are you still in education?\n(Tick the most relevant option)"]
[null,null,"If the answer to above is ‘yes’ then please give more details regarding your education"]
[null,"*","As of present are you in any type of work/employment? \nTick the most relevant option"]
[null,null,"If the answer to above is 'yes' then please give more details regarding your work"]
[null,null,"Please provide us with any other information you think is relevant"]
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[null,null,"EQUALITY & MONITORING"]
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[null,null,"The information you provide is strictly confidential and will be stored securely"]
[null,"*","Do you consider yourself to have a disability or health condition? \n(The information in this form is for monitoring purposes only)"]
[null,null,null,"How does your disability or health condition affect you? \nPlease write in here:"]
[null,"*","If the answer to the above is ‘yes,’ then do you require any reasonable adjustments to be put in place?"]
[null,null,null,"Please write which adjustments you would need: "]
[null,null,"What is your religion or belief?"]
[null,"*"]
[null,null,null,"If other religion or belief, please write it in:"]
[null,null,"What is your ethnicity? Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong"]
[null,"*","Are you married or in a civil partnership?"]
[null,"*","What is your sexual orientation?"]
[null,null,null,"If other, please write in:"]
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[null,null,"Why are you interested in our programme?"]
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[null,null,"How do you think the programme will benefit you?"]
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[null,null,"What are you looking for in a mentor?"]
[null,null,"Mention if you have any strong preferences in what you are looking for in a mentor. "]
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[null,null,"What are your aspirations in life?"]
[null,null,"State if there is anything you aspire to achieve in your professional/ personal life that you feel a mentor could support you with"]
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[null,null,"Activities and interests"]
[null,null,"Please briefly explain your activities and interests. It will help us match you better with a mentor"]
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[null,null,"Other information"]
[null,null,"If there is any other information you would like to provide then please let us know here:"]
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[null,null,"AGREEMENT & SIGNATURE"]
[null,null,"By completing this application, I agree to the goals and purpose of the mentoring programme. I will keep in regular contact with my mentor and inform the steering committee if I have any problems."]
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[null,null,"Name (printed)"]
[null,null,"Signature"]
[null,null,"Date"]
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[null,null,"OUR POLICY"]
[null,null,"It is our policy to provide equal opportunities without regard to race, colour, religion, national origin, gender, sexual preference, age or diability."]
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[null,null,"Thank you for completing this application form and for your interest in the inter-generational mentorship programme."]
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[null,null,"Please return all completed applications to: cyouthmentorship@gmail.com"]