Syracuse Disability Mentoring Day on October 17, 2018 at Drumlins!

Please answer each question to the best of your ability.

Last Name

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* 1. Last Name

First Name

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* 2. First Name

Gender

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* 3. Gender

Date of Birth (Ex: 03/25/1999)

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* 4. Date of Birth (Ex: 03/25/1999)

Date / Time
Street Address

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* 5. Street Address

City, State, Zip

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* 6. City, State, Zip

Email address of mentee (Ex: info@contact.com)

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* 7. Email address of mentee (Ex: info@contact.com)

Phone Number of Mentee-Format: (315) 555-5555

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* 8. Phone Number of Mentee-Format: (315) 555-5555

Highest Level of Education

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* 9. Highest Level of Education

What agency do you receive services from?  What school do you attend?  (Answer both if necessary)

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* 10. What agency do you receive services from?  What school do you attend?  (Answer both if necessary)

Person of Contact at Referring Agency/School (first and last name)

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* 11. Person of Contact at Referring Agency/School (first and last name)

Phone Number at Referring Agency/School: Format (315) 555-5555

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* 12. Phone Number at Referring Agency/School: Format (315) 555-5555

Job Preference (list three in general terms ex: working with animals, 
working in food services, etc.)

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* 13. Job Preference (list three in general terms ex: working with animals, 
working in food services, etc.)

Please list a phone number we can contact on the day of the event in case of an emergency: Format (315) 555-5555

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* 14. Please list a phone number we can contact on the day of the event in case of an emergency: Format (315) 555-5555

Do you need any accommodations on a job site? (ex: wheelchair access) If yes, please list below.

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* 15. Do you need any accommodations on a job site? (ex: wheelchair access) If yes, please list below.

Please list any dietary or medical needs you have:

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* 16. Please list any dietary or medical needs you have:

Is there anything additional you would like us to know about you?

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* 17. Is there anything additional you would like us to know about you?

By clicking the box below, you are stating that you have transportation to and from the breakfast/worksite you are assigned to.

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* 18. By clicking the box below, you are stating that you have transportation to and from the breakfast/worksite you are assigned to.

By clicking the box below, you allow us to take pictures of you that may be posted on the DMD website.

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* 19. By clicking the box below, you allow us to take pictures of you that may be posted on the DMD website.

Will you be attending the DMD Breakfast on 10/17/18?

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* 20. Will you be attending the DMD Breakfast on 10/17/18?

Will another person be attending the breakfast with you and  accompanying you to the work site?  If yes, please list their first and last name and their phone number.

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* 21. Will another person be attending the breakfast with you and  accompanying you to the work site?  If yes, please list their first and last name and their phone number.

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