External Real World Learning Form

Use this form to suggest a mentor or business for

School/Program Name

Thank you for completing this suggestion form. Your information will be submitted to the program below. The Coordinator will evaluate your suggestion and let you know if the opportunity has been added to their ImBlaze dataset.

Record Type ID

Suggestion ID

Status

Owner ID

Suggestion Source

School ID PrePre Pop

Student Placeholder Contact Pre Pop

This needs to be a default student contact ("External Form Submission" is the name and connected with the same School account.)

IC User Pre Pop

for Created By field

Your Contact Info

Your First Name

Your Last Name

Your Email

What best describes your role?

TeacherPotential Mentor/EmployerParentOther

Other

You will receive an email from donotreply@imblaze.org if/when your suggested opportunity is published.

Mentor/Organization Information

How are you connected to the person you are referring?

Have you made contact with this mentor or organization already?

I have contacted these folks already.

Please name this opportunity

Naming this can help the internship coordinator present this to the right students. You can uses terms like:
- Informational Conversation with an animal-loving Lawyer
- Guest Expert on Mechanical Engineering
- Law Internship
- Shadow a Doctor

Opportunity Name

Opportunity Details

Feel free to describe this opportunity

Feel free to include any additional information that you think would be helpful to describe this experience to young people.

Number of Positions Available

if known. otherwise leave as "1"

Times (if known)

Morning

Afternoon

All Day

No preference

Check here if you know an expected start date for this experience.

Expected Start Date

Do you know if their is an application process?

Yes, there is.

No, there is not.

Unsure

Application due date

Internship Photo

This can be the company logo, or a photo of the business. png, jpg files that are approximately 370x270px

Virtual Internship Information

I expect this internship to be all or in-part virtual.

Virtual URL

Company/Org Info

Company or Organization Name

Company/Org Website

htttp://www.google.com

Street

City

State

Zip/Postal

Country

Company Phone

Company Email

Company or Org Description

Feel free to describe this business or organization.

Mentor/Expert Info

First Name

Last Name

Title

Profession

Choose the best fit. Leave blank if unsure.

Phone

the url for the mentors linkedin profile: https://www.linkedin.com/in/davidnathanielberg/

Email

Bio