Disability mentoring Day
October 21, 2009
MENTOR APPLICATIONYork & Cumberland County |
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DMD enables students and young adults 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 this mentor application by August 28th and return to your Company or Agency’s DMD Coordinator or submit directly to: James Howard, Bureau of Rehabilitation Services, 185 Lancaster Street, Portland, ME 04101; fax: 775-7870; email: james.e.howard@maine.gov
SECTION I: GENERAL INFORMATION
Last Name: ________________ First Name: ________________
Name of Business, Government Agency, or Non-Profit Organization:
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Address: ___________________________________________________________
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Phone (Voice): __________________ TTY: _________________
Email: _________________________________________
SECTION II: WORK EXPERIENCE INFORMATION
Job Title: ___________________________________________________________
Summary of General Job Responsibilities: ___________________________________________________________
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SECTION III: 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.
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SECTION IV: 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: ___________________________________________________________
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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 V: 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 FORMYork & Cumberland CountyReturn to: |
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.
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Signature
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Date
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Printed Name