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DMD Mentee Application
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First Name
Email
Birthday
Last Name
Phone
Gender
Name of School/Learning Center
*
Buhler
Fairfield
Haven
Hutchinson
Nickerson
Pretty Prairie
Sterling
TLC
Current Education Level
*
10th
11th
12th
Other
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CAREER INTERESTS
Describe one or more Jobs/Careers that interest you and explain why:
Option 1:
Option 2:
Option 3:
Have you participated in Disability Mentoring Day in the past?
Yes
No
If yes, please list where you have been placed for mentoring:
Will you need any accommodations to participate in DMD such as alternative format? (Braille, Large Print, Sign Language Interpreters etc.)
Yes
No
If yes, please specify:
SCHOOL OR PROFESSIONAL CONTACT:
(Teacher, Para-professional, Counselor, Service Provider)
First Name
Last Name
Title
Email
Phone
Will this student require special transportation/PARA?
Yes
No
If yes, please explain:
Any special dietary restrictions?
Yes
No
If yes, please explain:
Apply Now >
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