Music Education Hub Mentoring Programme 2017/18

Mentee Application Form Confidential

1 Name

2 Job Title

3 Organisation

4 Contact details:

Address

Telephone Mobile E-mail

Questions 4–8 will enable us to carry out equal opportunities monitoring.

5 Are you Male Female

6 Age Under 31 31–45 46–60 61–70

7 What would you describe as your cultural/racial origin?

8 Do you have any access requirements? Yes No

If yes, do you have any specific requirements?

9 What are the areas within your organisation that you would like to improve?

10 What are the particular areas you wish to work on with a mentor?

11 What do you hope to gain from working with a mentor?

12 Do you have any preferences in relation to your mentor, such as type of experience or areas of knowledge?

13 When will you be available for meetings? Day Late afternoon Evening

14 You will probably meet at the mentor’s office or on neutral ground. How far could you travel to meet with a mentor, if necessary?

15 Will you need to travel by public transport?

16 What are your outside interests?

17 Is there any other information about yourself that you feel may be relevant when we are matching you with a mentor?

Signature Date

If you return this form electronically from your own email address, then the signature will be presumed to be present.

Data Protection Act 1998: We are required by law to obtain your ‘informed consent’ to hold your personal details on our databases. Vivienne Tyler trading as Business in the Arts holds a database of individuals and organisations with whom it works. Your information is entered on to our database and it will be used for internal administration, monitoring and to contact you regarding the Mentoring programme. Your details will only ever be passed to an individual that you have consented to meet with or work with through the programme.

Do you consent to your personal details being stored on Business in the Arts database?

Yes No

Please return this form along with your completed Self-evaluation form, CV/career summary and Job Description by 7 August 2017 to:

Vivienne Tyler. Email:

Telephone: 07903 369 896