1. Forename
2. Surname
3. Address (inc. postcode)
4. Telephone (day)
5. Telephone (eve)
6. Mobile
7. Email
8. Date of birth
9. Gender
10. Emergency contact name
11. Emergency contact number
The information below is to help us to support you properly, it will not affect your ability to be an Community Mentor.
12. Are you a member of any Community Groups / Clubs / Local Societies. Please list.
13. Are there any groups who you may be able to work with to produce an action plan?
If yes, which?
14. Did a national organisation encourage you to become a Mentor?
If yes, which?
15. Do you have any experience of working with community groups?
If yes, please give details.
16. Do you have any experience of sustainable development issues? (For example: recycling, saving energy, ethical shopping (food miles, etc), climate change)
If yes, please give details.
17. Have you any learning support need or disability that may affect your learning?
If yes, please give details.
18. Do you have any medical condition(s) that we need to be aware of?
If yes, please give details.
19. Any other information that we may need to know? (e.g. dietary requirements)
20. Please select your nearest BTCV Scotland office Please select Stirling (Head Office) Glasgow North Lanarkshire Johnstone Toryglen Ayr Auchinleck Edinburgh Fife West Lothian Aberdeen Inverness
To ensure we are reaching all sections of the community please fill in the questions below
Choose ONE section from A to E and tick the appropriate box to indicate your cultural background.
A. White British Irish
Other, please specify:
B. Mixed White and Black Caribbean White and Black African White and Asian
Other, please specify:
C. Asian or Asian British Indian Pakistani Bangladeshi
Other, please specify:
D. Black or Black British Caribbean African
Other, please specify:
E. Chinese or other ethnic group Chinese
Other, please specify:
Please tick the appropriate box to indicate your age 18-25 25-35 35-45 45-55 55-65 65-75 Over 75
Would you describe yourself as having a disability?
I consent to the personal details supplied on this form being used by BTCV Scotland to facilitate my involvement in the Community Mentors Programme only. Yes
