MENTOR APPLICATION [City Name] Area Return by Fax to (___) ___-____ or Return by Email to: [Email Address] DMD enables students and job seekers to spend part of a day visiting a business or government agency. This is an opportunity to underscore the connection between school and work; evaluate personal goals; target career skills for improvement; explore possible career paths; and develop lasting mentor relationships. Thank you for being a mentor! Please complete the mentor application and return to your Agency’s DMD Coordinator who will submit your form to Insert Local Coordinator/Agency. Insert Local Coordinator/Agency must receive your application by Insert Time on Insert Due Date. SECTION I: GENERAL INFORMATION Last Name: ________________________ First Name: _____________________________ Name of Business, Government Agency, or Non-Profit Organization: ________________ Address: __________________________________________________________________ Phone (Voice): _____________ TTY: _______________ Email: ____________________ SECTION II: WORK EXPERIENCE INFORMATION Job Title: __________________________________________________________________ Summary of General Job Responsibilities: ______________________________________ ___________________________________________________________________________ SECTION II: WORKPLACE Below, please check the setting that most accurately describes the place at which you work. ___ Private business ___ Government agency ___ Non-profit organization ___ Educational Institution Is your facility wheelchair accessible? ___ Yes ___ No Does your business, organization, or agency offer internship opportunities? If so, please briefly describe these opportunities, including the areas of focus for such a program. If the mentee pool permits, we will do everything we can to match you up with students who may be interested in separately applying for an internship that your organization may be offering. Feel free to include web sites to visit and to use additional sheets of paper. SECTION III: GENERAL INFORMATION FOR WORKPLACE COORDINATORS (OPTIONAL) If you are coordinating a Disability Mentoring Day program at your job site or would like to lead in such efforts in your office, please fill out this section. On-Site Agency or Organization Coordinator Name and Number: ___________________ ___________________________________________________________________________ Total number of Mentees to host: ___ Total number of Workplace Mentors to host: ____ Type of Activities: Check all that apply. ___ One-on-one job shadowing ___ Tour of company site ___ Small group discussion with all mentees ___ Lunch with mentees. ___ Lunch covered by mentor/organization ___ Mentee must bring own lunch or money for lunch Workplace Coordinators are asked to gather applications from their offices and submit applications to their DMD Local Coordinator. Every attempt will be made to match each Mentor with a Mentee; in the event that this is not possible, advance notice will be provided. SECTION IV: LEVEL OF MENTEES Please rank the grade level of mentees that you hope to host for Disability Mentoring Day. Every effort will be made to meet your preferences; however, please be prepared to meet undecided students who are exploring the world of work and how their interests can lead to different careers. ___ High school students ___ College students ___ Students in post-graduate work ___ Job seekers, not currently in school ___ No preference. The most important factor is area of interest. PHOTO RELEASE FORM [City Name] Area Return by Fax to (___) ___-____ or or return by email to [Email Address] TO BE COMPLETED BY ALL PARTICIPANTS PHOTO RELEASE: I understand that Disability Mentoring Day can attract attention from the media and that it is used to promote ongoing partnerships between schools, disability organizations, and employers. I hereby grant permission to be photographed for promotional and educational purposes. ____________________________________ ___________________________ Signature Date ________________________________________ Printed Name Insert Local Coordinator Contact Information (Organization, Address, Phone/TTY, Email, Fax, Website)