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2010 MENTORING PROGRAM REGISTRATION

If you would like to participate in the program, please complete the form below. This year the program will commence with the Mentoring Induction Workshop on April 15th, 5pm to 7pm at Level 1, 257 Collins Street.

2010 Mentoring Program Registration

* indicates required fields

* I would like to participate in the 2010 Mentoring program as a:


	Mentor
	Mentee
	Both Mentor and Mentee

* Are you a member of Victorian ICT for Women?


	Yes
	No

* Name:

* Please indicate what you are hoping to get out of your involvement in this program:

* Email:

Phone No:

* Street Name:

* Suburb

* Post code:

* Gender


	Female
	Male

* Preferred means of communication:


	Face to face
	Combination of face to face and e-mail

* Most suitable location for face to face meetings:

* Your Age Range:


	< 20 years
	20 - 25 years
	25 - 30 years
	30 - 40 years
	40 - 50 years
	50 years +

* Total number of years in the ICT industry:

* CURRENT EMPLOYMENT:

Current Employment Status:


	Full time
	Part time
	Casual
	Between positions
	Retired
	None

Please list the Professional Associations you have current membership with:

CURRENT JOB:

Years (From - To); Company; Title; number of direct reports

Job Field:

Additional details of current job (optional):

Current Employer Category:

PREVIOUS EMPLOYMENT:

Previous job field:

Details of previous job - include company; job title; years in role; number of direct reports etc.:

Short Job History (years; company; job title; job field):

* Please describe the type of person you would like to be paired with e.g. area of work; years experience.

Would you prefer to Mentor or be Mentored in ICT, Leadership or Both:

* Personal Statement (this will be used as an introduction to your mentor/mentee - please limit to 200 words max.):

* I understand that completing this form does not necessarily guarentee participation in the mentoring program. I understand that Vic ICT for Women will contact me to advise if I have been successful in securing a mentor/mentee partner.


	I agree

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2010 MENTORING PROGRAM REGISTRATION