e-Mentoring Registration
This form should be completed by the mentee applying for the Urban Synergy e-Mentoring Programme.

All information provided will be confidential and used solely by Urban Synergy for the purposes of evaluating the  Programme. Your contact details will not be disclosed to any 3rd party.

Please note, only complete this form once, you will receive an email confirmation within 20 minutes.

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First Name *
Last Name *
Personal Email *
Please provide a personal email address
Telephone number
Mobile phone number preferred
Date of birth *
Please enter DD/MM/YYYY format
Gender *
We will try and match you with a mentor that identifies in the same way as you.
Free School Meals *
Do you receive Free School Meals?
Ethnicity *
Address *
Enter house/flat number and street
Postcode *
Enter your postcode
Which school do you attend? *
If you cannot see your school on the list below, please complete the Register Interest form instead.
For safeguarding purposes, we need to gather some additional information about you should you wish to attend any Urban Synergy events.
Health *
Do you have any health issues/allergies or Special Education Needs (SEN) that we should be made aware of?
Dietary special requirement *
Vegetarian, gluten free, nut allergy etc
Image consent *
As a charity, we often publish pictures of our events on social media and our website. This is to provide evidence of our events to supporters and sponsors that allow us to provide mentoring programmes to young people. Please indicate below that you give consent for your pictures to be used should you attend future events.
About you
Hobbies and interests *
Do you have any other hobbies/interests e.g. Scouts, Cadets, computer programming, sports
What skills do you hope to gain from this programme? *
e.g. Career insights, Interview CV/Skills, Work place values, Confidence, Communication. Include all that apply
What career ambitions or industries do you want to work in? *
Provide one or more e.g. Law, IT, Science, Marketing, Sales, Finance. HR
What are your plans when you leave school? *
Current Skills *
Please rate your current skills on the following, please be honest, we're here to help!
Strongly Disagree
Strongly Agree
I can prepare a strong CV
I am confident about attending a job interview
I can build professional relationships/networking
I know what to expect in the workplace
I have good organisational skills
I have good presentation skills
I know what qualifications are needed for my future career
Intended Study *
Please list the subjects/course you are intending to study age 16+
First to go to university? *
If you do plan to go to university, would you be the first in your immediate family to do so? i.e. did your parents or older brother or sister attend?
Technology available *
Our e-Mentoring will rely on home broadband and equipment to talk/video call with your mentor. Please describe which equipment you have available and broadband speed reported by speedtest.net e.g. Windows 10 laptop with webcam, iPad/tablet, smart phone, Virgin Media 50Mb
How did you hear about the e-mentoring programme? *
Parent/Guardian Contact details
Please provide the name and contact details of your parent/guardian.
First Name *
First name of Parent/Guardian
Last Name *
Last name of Parent/Guardian
Parent or Guardian relationship *
What is your relationship to the person above i.e. are they your mother, father, grandmother etc
Phone number *
Mobile number preferable
email address *
Please provide your personal email address
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