Prairie Independent Living Resource Center - PILR

Graphical text that reads Prairie Independent Living Resource Center, Hutchinson Kansas

Dedicated to the full inclusion of people with disabilities.

Disability Mentoring Day
Mentee Application

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

Download this document in PDF

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

Full Name
Male Female
Date of Birth
Street Address
City
State
Zip Code
Telephone
E-mail Address

Education Information

Current Education Level
Name of School

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

Employment Experience Enter your employment experience here

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.

Career Choice 1

Career Choice 2

Career Choice 3

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.)

Please specify your accommodations Specify any needed accommodations here

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.

Please specify your dietary restrictions Specify any dietary restrictions here

Please indicate t-shirt size:

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

Contact Name
Contact Title
Contact Telephone
Contact E-mail
Contact Address
Contact City
Contact State
Contact Zip