CIPD London Mentoring Scheme
Mentor Sign Up Form
This information will be used in confidence by the CIPD London Mentoring Scheme coordinator to help match Mentors and Mentees. Unless agreed, it will not be made available
to anyone else. If agreed, only information from section 1, 2 & 3 (no personal/contact
details) will be added onto the Mentor Master Spreadsheet which will be accessible via the
Mentoring Scheme section of CIPD Central London branch website – allowing Mentees to
select their Mentor. If selected by a Mentee, we’ll inform you and also will send you his/her
Mentee Profile Form.
Fields/sections marked with a * are required.
Contact Information
First Name*
Last Name*
E-mail Address*
Telephone*
Address
Work Address
I agree for my summary to be included on
Mentor Master Spreadsheet (available via
Central London branch website)*
- YES
- NO
If selected by Mentee, I agree for my form to be
send to him/her for review*
- YES
- NO
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Equal Opportunity Monitoring Information
Gender:
Ethnicity:
Refer to categories
at bottom of form
Do you have a
disability?
If in doubt, refer to
definition at
bottom of form
1. What can you offer to a mentee/how you think you can help a mentee?*
(please give us approx only 100 word summary at this section – if agreed by yourself this information
will be made available to view by Mentees via our website)
2. Skills Summary*
(please give us approx only 100 word summary at this section – if agreed by yourself this information
will be made available to view by Mentees via our website)
3. Mentor Experience/Mentor Skills*
(please, let us know if you have any previous Mentoring experiences – if agreed by yourself this
information will be made available to view by Mentees via our website)
4. Service Area
(please, let us know which London areas you are willing to cover/travel to in order to meet with your
Mentee – if agreed by yourself this information will be made available to view by Mentees via our
website)
5. Commitment & Availability
(how long you are willing to mentor for, how many mentees you are willing to take on, when are you
available, etc.)
6. Reason for mentoring
(please, let us know why you decided to mentor)
Once you have completed the form, please save it and send to the CIPD
London Mentoring Scheme Co-ordinator Monika Michalikova at
[email protected]. If you move location or job, please let the Mentoring
Scheme Co-ordinator know your new contact details.
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Ethnic Origin (Census categories)
White British
White English
White Welsh
White Scottish
White Irish
White Other
Mixed White and
Black Caribbean
Mixed White and
Black African
Mixed White and
Asian
Mixed Other
Asian British
Indian
Asian British
Pakistani
Asian British
Bangladeshi
Asian British
Other
Asian English
Indian
Asian English
Pakistani
Asian English
Bangladeshi
Asian English
Other
Asian Scottish
Indian
Asian Scottish
Pakistani
Asian Scottish
Bangladeshi
Asian Scottish
Other
Asian Welsh
Indian
Asian Welsh
Pakistani
Asian Welsh
Bangladeshi
Asian Welsh
Other
Black British
Caribbean
Black British
African
Black British
Other
Disability
Under the Disability Discrimination Act, a disability is defined as ‘a physical or mental impairment
that has a substantial and long-term adverse impact on the ability to carry out normal day-to-day
activities’
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