MENTEE APPLICATION [City Name] Area Return by Fax to (___) ___-____ or Return by Email to [Email Address] DMD enables students and job seekers to spend a day visiting a business of government agency that matches their interests to have one-on-one time with volunteer Workplace Mentors. This is an opportunity to underscore the connection between school and work; evaluate personal goals; target career skills for improvement; explore career paths; and develop lasting mentor relationships. To participate, complete this form and SUBMIT BY: ____________________ SECTION I: GENERAL INFORMATION Last Name: __________________ First Name: __________________ Date of Birth _________ Address: ______________________________________________________________________________ Landline Phone: __________________ Cell: _________________ TTY: ____________________ Email: ___________________________________________________ If you are interested in disclosing your disability for the purposes of possibly being matched with a person with the same or similar disability, please describe your type of disability here: SECTION II: EDUCATION Please check one of the following. ___ High school, attending: Grade: _____ Graduation Date: _____ ___ Vocational School: Grade: _____ Graduation Date: _____ ___ College/University, attending _____________________________________________ Major(s) or area of interest: _______________________________________________ Expected Date of Graduation: _____ ___ Post-Graduate School, attending: _________________________________________ Degree(s): _____________________________________________________________ Expected Date of Graduation: _____________________________________________ ___ Job seeker (not currently in school) Highest level of education attained (Check One): ___ Some high school ___ College Degree:______________________________ ___ High School Diploma ___ Post-Graduate Degree(s): _____________________ ___ Vocational License ___________________________________________ SECTION III: DMD COORDINATOR Name and Title: ___________________________________________________________________ Address: ________________________________________________________________________ Landline Phone: ___________ Cell: ___________ TTY: __________ Fax: __________ Email: __________ SECTION V: REASONABLE ACCOMMODATION REQUESTS Please check if applicable: ___ Braille ___ Sign Language Interpreter ___ Computer disk ___ Oral __ Tactile __ ASL ___ PSE ___ Large print ___ Dietary needs__________________________ ___ Wheelchair access ___ Other_________________________________ SECTION VI: GOALS, INTERESTS, AND HOBBIES (OPTIONAL) On separate sheets of paper, briefly answer the following questions. Though optional, we strongly encourage you to take advantage of this opportunity to provide more information, since this will help event organizers with the Mentor/Mentee matching process. Also, feel free to include a resume. 1.) What do you hope to get out of Disability Mentoring Day? 2.) What are your long-term career goals? 3.) Describe your major(s) and/or educational interest(s) 4.) Beyond high school, from what schools have you graduated and when? 5.) Describe your paid and/or unpaid work experience (if any). Include extracurricular activities, internships, and community service work. 6.) Describe job-related skills that you have (if any). If not, what skills do you hope to gain? For more information about DMD: [Organization Name] * [Organization Address] [City, State, Zip] * V (___) ___-____ * TTY (___) ___-____ [or V/TTY (___) ___-____] Fax (___) ___-____ * [Email Address] * [web site] CAREER CLUSTERS WORKSHEET NAME: ____________________________________________________________________________ On Disability Mentoring Day, Mentees may be paired with a Workplace Mentor at a job site. To make your experience more meaningful, please rate your top three choices among the following career clusters. If possible, you will be paired with a person in one of the clusters you selected. INSTRUCTIONS: Place the number of your choice next to the appropriate career cluster below. 1 = First Choice 2 = Second Choice 3 = Third Choice _____ Arts and Communication: Do you like to communicate ideas? Do you like to share information? Are you creative, imaginative and innovative? Do you like to express yourself in writing or with audio, visual or graphic media arts? Do you like to perform? Could you imagine yourself working at a museum or in other settings that promote and celebrate artistic expression? _____ Business and Marketing: Are you organized, accurate and self-motivated? Are you a leader? Do you enjoy organizing people and planning events? Do you like computers and business machines? Do you like creating reports? Do you like marketing things? Do you enjoy working with numbers? _____ Education: Would you enjoy teaching either children or adults in an academic setting? _____ Food, Recreation, and Hospitality: Do you enjoy the preparation of and/or serving of food either in a cafeteria or restaurant setting? Do you like organizing recreational activities such as social outings, competitive sports, arts and crafts, and picnics? Do you like putting together the logistics for conferences and conventions, community service projects, or other endeavors surrounding community relations? Do you enjoy being around people and picture frequent interaction with others as a vital part of your ideal work environment? _____ Health and Medicine: Do you like to work with people? Are you interested in wellness and nutrition? Are you interested in working as a doctor, nurse, nurse practitioner, or medical assistant? Do you like new technology? Are you interested in medical research and figuring out the causes of diseases? Can you stay calm in an emergency? _____ Human Services: Are you able to get along with a diverse group of people? Do you like serving the public? Do you have leadership ability? Are you patient and polite, yet able to make decisions? Are you dependable and hardworking? _____ Law, Government, and Public Policy: Do you like to follow current events? Do you like to learn about local, state, national, or international politics? Are you interested in how laws are enacted? Do you aspire to hold elected or appointed political office? Do you like speech and debate? Do you see yourself arguing a case in court? Do you like conducting research on the law, its practical application, and how it is interpreted? Do you envision helping to draft major public policy on issues you care about? _____ Law Enforcement: Do you want to work as a police officer, sheriff, marshal, detective, or criminologist? Would you be interested in investigating and solving crimes? _____ Natural Resources, Environment and Agriculture: Do you like the environment? Do you like working with plants and animals? Are you interested in physical resources such as land, water, soil, and weather? Do you like to observe, learn, investigate and solve problems? _____ Technology, Engineering and Science: Do you enjoy math, technology, or science? Do you have the ability to be accurate, analyze data, and solve problems? Do you like designing things or drawing detailed plans? Do you like using machines and heavy equipment? _____ Other: Do you fall into a category not directly covered above? If so, state your preference in the space provided on the previous page. 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