Your name

Your phone

Your address

Your City/State

Your zip code

Your email

Your web site

Field of Dance: Ballet/Pointe Tap Jazz Modern Gymnastics

Dance Therapy Sports Medicine Drill Team/Cheerleading Costume Design

Stage Design Journalist/Historian Art Choreography Labanotation Production

Other (please specify)

I function as: Teacher Coach Performer Director

Therapist Technician Artist Writer

Choreographer Producer Sewing Technician

Other (please specify)

My professional affiliations include

Letters of reference may be obtained from

I am interested in becoming a Career Mentor in the National Dance Week Mentoring Program. If accepted, I would agree to the inclusion of my name, address, phone and Email address (if applicable) on all Mentor listings published by NDW. I would also be willing to serve as a volunteer Mentor to any individuals assigned to me in their search for information, guidance and advice on a career in my field of expertise. ( Fill out and submit application above.)

Name_________________________________________________________________

Address____________________________________ Phone __________________

City________________________State_____Zip Code_________________________

Email address___________________ Website ____________________

Field of Dance:
Ballet/Pointe ______ Tap ______ Jazz _______ Modern _________

Gymnastics ______ Dance Therapy ______ Sports Medicine ______

Drill Team/Cheerleading ________ Costume Design _______

Stage Design _______ Journalist/Historian _______ Art _______

Choreography ______ Labanotation ______ Production ______

Other (please specify) ____________________________________

I function as: Teacher _____ Coach _______ Performer _______ Director ______

Therapist ______ Technician ______ Artist _______ Writer ______

Choreographer ______ Producer ________ Sewing Technician _________

Other (please specify) _____________________________________

My professional affiliations include: ________________________________________

________________________________________________________

Letters of reference may be obtained from:___________________________________

_______________________________________________________

Signature:________________________________________________________

Either Fill out the online form above & press Submit or
Print this form out, complete, and mail to:
Patricia Goulding
NDW Executive Director
142 Parkedge Rd
Pittsburgh, PA 15220.