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The PILR logo is a dark outline of a building with six Roman-style columns each with a stalk of wheat in a contrasting color. The letters PILR appear in contrasting color at the roofline.Graphical text that reads Prairie Independent Living Resource Center, Hutchinson Kansas

Dedicated to the full inclusion of people with disabilities.

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DMD LogoDisability Mentoring Day
Mentee Application

DMD Home   • DMD Fact Sheet   • DMD Teacher Tip Sheet   • DMD Mentee Tip Sheet

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The application to be a DMD Mentee is located below. All fields are required.
Application deadline in September 17, 2010 for Law Enforcement and Medical,
and September 24, 2010 for all other careers.

Download the Permission to Participate in DMD Form

Personal Information









Education Information


Employment Experience
(or other volunteer activities, hobbies, etc.)

Career Interests
List in order of preference 3 different careers you might be interested in after high school. Please enter a career in each field.


The steering committee will make every effort to place you with a mentor in your first career choice. However, if that isn’t possible we will use your second and third choices to find you a placement.

Other Information
Will you need any accommodations to participate in DMD such as alternative format?
(Braille, Large Print, Sign Language Interpreters, etc.)


Do you have any dietary restrictions that the DMD committee needs to be aware of such as needing a diabetic meal? If so please explain.


School or Professional Contact
(Teacher, Professor, Counselor, Service Provider)