Allies
SECTION I: GENERAL INFORMATION
Name of On-Site Coordinator

Coordinator Email

Phone

Backup Contact Name

Backup Contact Phone

Name of Business, Government Agency, Non-Profit Organization or Educational Institution

Address

City

State

Zip

County

SECTION II: WORK EXPERIENCE INFORMATION
Job Title

Summary of General Job Responsibilities

Workplace Description

Is your facility wheelchair accessible?
YES   NO

Internship Opportunities
Does your business, organization, or agency offer internship opportunities? If so, please briefly describe these opportunities, including the areas of focus for such a program. Feel free to include web sites to visit and to use additional sheets of paper.

: GENERAL INFORMATION FOR WORKPLACE
If you are coordinating a Disability Mentoring Day program at your job site or would like to lead in such efforts in your office, please fill out this section. Check all that apply.
Introduction to Various Employees
Opportunity for Students to Shadow Employee/Employees
Tour of company site
Overview Presentation of Company

If mentees are visiting your facility during lunch time please check the following:
Lunch will be covered by mentor/organization
YES   NO
Mentee must bring own lunch
YES   NO
Mentee must bring money for lunch.
YES   NO
If so how much $

Lunch N/A
YES   NO

Maximum number of students you are willing to host

Total number of support staff you are willing to host

On-Site Parking Information

Name of representative to meet the day of the event

Where will students report at the beginning of the day?

Will your presentation and/or tour be inside, outside or both?
Inside
Outside
Both

Hours in which you would like to host students. Please keep in mind that many students do not arrive at school until after 8am. Please let us know what times work for you and your organization:

FROM:
  TO:

CareerClusters
ADMINISTRATION, such as:
Clerical, Data Entry, Office Management, Customer Service/Receptionist Duties

BUSINESS/FINANCE, such as:
Accounting, Auditing, Budget, Entrepreneurship/Business Owner, Payroll, Procurement

COMMUNICATION, such as:
Editor/Writer, Event Planning, Media Relations, Publishing (design, editorial, production)

HUMAN RESOURCES, such as:
Employee Development, Employee Relations/Performance, Diversity/Equal Employment, Labor Relations, Staffing/Recruiting

LAW, such as:
Law Enforcement/Security, Legal (attorneys, paralegals, judges)

MILITARY

MUSEUMS, such as:
Advanced Studies (Historian), Collections/Art and Artifacts (Archivist: Curatorial Duties; Registrar Conservation; Film/Video; Oral History), Education (Community Partnership; Outreach), Exhibition (Exhibition Development; Exhibition Research Historian; Traveling Exhibition; Special Exhibition Coordinator)

PERFORMING ARTS, such as:
Dance, Theatre/Musical Theatre, Music/Opera/Singing

PUBLIC POLICY, such as:
Agriculture, Economics, Education, Employment, Environment, Health, Transportation

REHABILITATION/SOCIAL WORK, such as:
Physical Therapy, Rehabilitation, Social Work

OPERATIONS, such as:
Facilities Management: Building Engineer, Maintenance Support Services: Food Service, Loading Dock, Mail Operations, Supply Management

TECHNOLOGY, ENGINEERING, AND SCIENCE, such as:
Scientist, Computers, Information Technology, Computer Engineering, Computer Science

OTHER (please describe)