Savannah Intercultural Institute

Since 2003
Community mentorship membership form

Draft form for review. Dedicated Institute contact details and submission arrangements will be confirmed before live registration. Mentees: ages 16–35. Mentors: ages 18+. Senior Friends are welcome from any country.

1. Applicant details

I am applying as: □ Mentee □ Mentor □ Senior Friend

Full name *

Date of birth * (mentee / mentor)

Sex / gender *: Female / Male

Country of residence *

Province (Zambia residents) *

District (Zambia residents) *

Community / area / city *

Phone number *

Email address (required for mentors)

Current occupation * (pupil, student, worker, businessperson or doing nothing)

Marital status *: Single / Married / Engaged / Divorced / Widowed (widow / widower)

Occupation and marital status apply to mentee and mentor applications.

Parent / guardian contact for mentees under 18

Parent / guardian full name *

Relationship *

Parent / guardian phone number *

The team must obtain and record guardian consent before participation. These contact details alone do not establish consent.

2. Mentee and Senior Friend interests

Mentee: what would you like mentorship to help you with?

□ I commit to the K30 annual membership contribution and to following the programme rules. If I need help with payment, I can discuss support arrangements with the team.
□ I would like help with the K30 annual membership fee.

Senior Friend connection: New friend / Alumnus / Former mentor or volunteer / Partner

Senior Friend: how would you like to support or participate?

All applicants

□ I understand that Savannah will use these details to follow up about my application and arrange appropriate participation.
□ I would like optional Savannah news and learning updates.

Applicant signature / mark

Date

3. Mentor applicants

Highest level of education (select one):
□ Primary school
□ Junior secondary school (Grades 8 and 9)
□ Senior secondary school (Grades 10 to 12)
□ College certificate
□ College diploma
□ Bachelor’s degree
□ Master’s degree
□ PhD

Why do you want to become a mentor under Savannah Intercultural Institute?

Your experience and areas you could mentor:

□ I acknowledge that mentorship is wholly voluntary. It does not earn salary, payment, points or other financial rewards and creates no entitlement to compensation.
□ I have read the mentor commitments and am ready and willing to follow the conduct, safeguarding, training and supervision requirements.

Read the full commitments on the website or request a printed copy before signing. Mentor registration is followed by review, training and approval before you can lead a group.

Mentor signature / mark

Date

Staff use only

Reference: _______________________ Intake: Online / Paper / Phone / Assisted

Recorded by / date: _______________________ Identity: Pending / Complete

Guardian consent: N/A / Pending / Recorded Placement: Pending / Assigned

Club / coordinator: _______________________ Fee: Paid / Deferred / Sponsored / Waived