Workplace Mentor Registration Packet – Animal Care Services

Email

This field is for validation purposes and should be left unchanged.

Workplace Details

Thank you for volunteering to be a Workplace Mentor for an ACAC student!
You're playing an important role in shaping the next generation of animal care workers — and we truly appreciate your support.

Before you begin, please have all your documentation ready:

Your animal care related qualification, you will need to upload a copy. If you are not qualified, we will ask for details of the CPD you have attended recently.
If you’re a veterinarian or an AVNAT-registered veterinary nurse or technician, we only need your current registration number. Your registration must be valid and current (not expired).
If you’re a vet nurse or technician not registered with AVNAT, we’ll need a
copy of your VN or VT qualification
Details of your current and previous employer

Firstly, we need to see if your workplace is already registered with us and the registration is current.

If your workplace is not registered, that's ok — we just need to organise that first, before we register you.

STEP 1: SELECT THE WORKPLACE'S STATE(Required)

Select the state the workplace is based in.

STEP 2: SELECT THE WORKPLACE(Required)

This list will show any workplaces registered with us already and check the registration expiry date. If you workplace's registration is expired, you will be directed to register the workplace first.

This field is hidden when viewing the form

ORGID(Required)

This is the organisation ID from Axcelerate grabbed from the spreadsheet once they select the clinic.

This field is hidden when viewing the form

Clinic Registration Expiry Date(Required)

Month

Day

Year

This field is hidden when viewing the form

Expiry Date for JS Display

Workplace Address(Required)

THESE ARE THE DETAILS WE HAVE ON FILE FOR YOUR WORKPLACE. Please verify that this is the workplace you are working at before continuing.
EDITS MADE HERE WILL NOT UPDATE OUR SYSTEM. This is for verification purposes only.

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

SORRY — your workplace's registration expired on .

You will need to register again.

Please complete the form by clicking here.

Once registered, it can take up to 24 hours for your clinic to appear in our system.

That's fine!

Let's get your workplace registered first.

Please complete the form by clicking here.

Once registered, it can take up to 24 hours for your clinic to appear in our system.

Your workplace is currently registered with us and expires on .

Let's go ahead and get you registered as a Mentor.

Workplace Mentor Details

This is about YOU.

Mentor Name(Required)

Prefix First Last

Position in the Workplace(Required)

Personal Phone/Mobile(Required)

Private Email(Required)

This must be an email account only you can access (personal or work based), not a group access account that others can access.

Home Address(Required)

Please enter in your home address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

USERNAME & PASSWORD

Please set a username and password that will be used to access the Mentor Only information on this website, once you have been approved.

Username

Password

Enter Password Confirm Password

Student Details

Please list the student/s you will be mentoring at the above named workplace and indicate if you are their primary mentor.(Required)

If known, please enter in the students that you are mentoring. To add more people click the (+) at the end of each row.

Full Student Name

RECENT EMPLOYMENT

Please enter details of your last two animal carepaid positions, starting with your current employment. We may contact the workplace/s to confirm these details are correct. If you have only worked in your current workplace, you can ignore the second slot.

Current position(Required)

Employment Start Date(Required)

Main Duties(Required)

Previous position

Previous Workplace Name

Previous Workplace Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Employment Start Date

Employment End Date

Main Duties

CONTINUING EDUCATION

Please enter details of the last FIVE continuing education events you have attended, pertinent to animal care. This can include training undertaken in your workplace with reps or colleagues (in house).

Description of course/seminar/conference 1(Required)

Delivery Mode(Required)

Year(Required)

Description of course/seminar/conference 2(Required)

Delivery Mode(Required)

Year(Required)

Description of course/seminar/conference 3(Required)

Delivery Mode(Required)

Year(Required)

Description of course/seminar/conference 4(Required)

Delivery Mode(Required)

Year(Required)

Description of course/seminar/conference 5(Required)

Delivery Mode(Required)

Year(Required)

WORKPLACE MENTOR SIGNATURE SAMPLE

We require a copy of your signature for verification purposes (against submitted work from students).

Please take a sheet of plain white or black paper and clearly sign your full name. If you typically use a shortened version or initials as your signature, please include that as well.

Once complete, take a clear photo of the signed paper and upload the image using the field below.

Upload a sample of your signature(Required)

Please follow the instructions above and upload here a sample of your full and shortened (if applicable) signature.

Drop files here or

Accepted file types: png, jpg, Max. file size: 1 MB, Max. files: 1.

MENTOR DECLARATIONS

Signature(Required)

Workplace Mentor Registration

Workplace Details

Workplace Mentor Details

USERNAME & PASSWORD

Student Details

Mentor Eligibility

RECENT EMPLOYMENT

CONTINUING EDUCATION

WORKPLACE MENTOR SIGNATURE SAMPLE

MENTOR DECLARATIONS