LOCAL COORDINATOR PROPOSAL FORM Proposed Location (Town, City, County): __________________________________ Name(s) of Proposed Local Coordinator(s): ________________________________ ______________________________________________________________________ Organization(s): _______________________________________________________ Mailing Address: _______________________________________________________ _____________________________________________________________________ Phone: _________________________ TTY: _________________________________ Fax: ___________________________ E-mail: _______________________________ Other Contact Info:_____________________________________________________ ______________________________________________________________________ Relationship between organization's mission and National Disability Mentoring Day: ________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ______________________________________________________________________ American Association of People with Disabilities (AAPD) 1629 K Street NW, Suite 503, Washington DC 20006 V/TTY: 202-457-0046/ 800-840-8844 7 Email: dmdaapd@aol.com 7 www.dmd-aapd.org Preliminary Members of Local Organizing Committee (with Organizations): ______ ______________________________________________________________________ ______________________________________________________________________ Target group(s): ____ High School Students ___ College Students ____ Job Seekers Estimated Number of Mentees: ___________ Proposed Date(s) of Activities: ___________________________________________ ______________________________________________________________________ Proposed Type of Activities (e.g., one-on-one shadowing, group visits, plenary gatherings): ____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________ __________________________ Signature(s) Date _______________________________________ Printed Name(s) ____________________________________________________________________________ American Association of People with Disabilities (AAPD) 1629 K Street NW, Suite 503, Washington DC 20006 V/TTY: 202-457-0046/800-840-8844 - Email: dmdaapd@aol.com - www.dmd-aapd.org