DO-IT Pals Application

Name: (required)

Mailing Address: (required)
Enter Mailing Address (required)

City: (required)

State: (required)

Zipcode or Postal Code: (required)

Country: (optional)

Phone: (optional)

Email: (required)

Parent/Guardian Email or Mailing Address: (required)
Enter Parent/Guardian Email or Mailing Address: (required)

High School Name and Location: (optional)
Enter High School Name and Location: (optional)

Your Grade Level: (required)

Expected Date of Graduation: (optional)

Date of Birth: (required)

Sex: (required) Male Female

Ethnicity: (optional)

Disability: (required)
Enter Disability: (required)

Academic and other awards (if any): (optional)
Enter Academic awards (if any): (optional)

1. Please describe what your interest has been in science and mathematics courses. (optional)
   Enter answer to question 1 (optional)

2. Describe your educational and career goals. (required)
   Enter answer to question 2 (required)

3. Please state in 100 words or less why you would like to be a DO-IT Pal. (optional)
   Enter answer to question 3 (optional)

4. What is your disability? How does it affect your ability to learn and/or complete classwork? (optional)
   Enter answer to question 4 (optional)

5. Do you have access to a computer regularly? (optional) Yes No
   If yes, does your disability require that you use special software or hardware in order for you to use a computer and, if so, what adaptive computer hardware and/or software have you used? (optional)
   Enter answer to question 5 follow-up (optional)

6. Do you have regular access to the Internet? (optional) Yes No
   If yes, please explain through which organization or service you have access. If no, explain how you plan to obtain access. (optional)
   Enter answer to question 6 follow-up (optional)

Additional Comments: (optional)
Enter Comments (optional)

I have reviewed the DO-IT Pals publication and agree to the guidelines of becoming a DO-IT Pal. (required)

All DO-IT Scholars program offerings are contingent upon receipt of grant funding.

The University of Washington ensures equal opportunity in education regardless of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, disability, disabled veteran, or Vietnam era veteran status in accordance with University policy and applicable federal and state statutes and regulations. 7/96