Apply to be a Mentor: Change Your Impact 2021 1. Contact Details1.1 Full Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title Given Name(s) Surname 1.2 Email Address* Enter Email Confirm Email 1.3 Phone Number*2. Questionnaire2.1 Please provide a brief bio that we can share with your mentee.*[max. 250 words]2.2 What interests you about being part of the mentoring program?*[max. 250 words]2.3 Please select three skill areas that you feel comfortable mentoring on:* Strategic planning Public advocacy Communication styles Career development Leadership skills Governance Staff management 3. Declaration & Privacy3.1 Declaration*We will use the information provided to match you to a mentee. Matching will depend on numbers of Change Your Impact 2021 participants. We may not be able to match everyone. If you are not matched, would you like us to hold onto your details for future mentoring opportunities? Yes No Electronic Signature*Date* Date Format: DD slash MM slash YYYY
