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

Please answer the questions below to the best of your ability.

Last Name

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* 1. Last Name

First Name

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* 2. First Name

Name of Business/Government Agency/Non-Profit Organization

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* 3. Name of Business/Government Agency/Non-Profit Organization

Street Address of the Business

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* 4. Street Address of the Business

City, State, NY

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* 5. City, State, NY

Phone Number of Business-Format (315) 555-5555

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* 6. Phone Number of Business-Format (315) 555-5555

Email address of Mentor

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* 7. Email address of Mentor

First and Last Name of Person who will be the Contact at the Job Site
for the Mentee

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* 8. First and Last Name of Person who will be the Contact at the Job Site
for the Mentee

Job Title and Brief Description of General Job Responsibilities

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* 9. Job Title and Brief Description of General Job Responsibilities

Exact Location/Address of Where Mentee will be Placed

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* 10. Exact Location/Address of Where Mentee will be Placed

Please check the setting that most accurately describes the place at which the Mentee will be placed:

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* 11. Please check the setting that most accurately describes the place at which the Mentee will be placed:

Is your facility wheelchair accessible?

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* 12. Is your facility wheelchair accessible?

Are there any special requirements or clearances for hosting?

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* 13. Are there any special requirements or clearances for hosting?

What type of mentoring will be provided to the mentee? (check all that apply)

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* 14. What type of mentoring will be provided to the mentee? (check all that apply)

What will occur after the mentoring experience?

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* 15. What will occur after the mentoring experience?

Total number of mentees business is willing to host:

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* 16. Total number of mentees business is willing to host:

Will mentor be attending the DMD Breakfast on the morning of 10/17/18?

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* 17. Will mentor be attending the DMD Breakfast on the morning of 10/17/18?

If yes, how many people will be attending from your institution?  Please list names if possible.

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* 18. If yes, how many people will be attending from your institution?  Please list names if possible.

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