AccessSTEM Team Application

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Are you a high school or college student with a disability?

Would you like to gain valuable experience through paid internships and other work-related opportunities?

Are you interested in the fields of science, technology, engineering, or mathematics?

Would you like to communicate with mentors working in these fields?

If so, then apply now to become a member of our AccessSTEM Team!

DO-IT (Disabilities, Opportunities, Internetworking, and Technology) at the University of Washington supports college-capable students with disabilities as they pursue challenging academic programs and careers. DO-IT's Alliance for Students with Disabilities in Science, Technology, Engineering, and Mathematics (AccessSTEM) is a project funded by the National Science Foundation (award #HRD-0227995 and #HRD-0833504). The purpose of the project is to increase the number of people with disabilities in science, technology, engineering, and mathematics (STEM) careers by encouraging and supporting students with disabilities who show interest and aptitude in STEM. These students become part of the AccessSTEM Team, engaging in an on-line community of peers and professionals, paid internships, other work experiences, research opportunities, and other activities as they transition to college, graduate school, and employment.

We are recruiting high school and college students with disabilities to join the AccessSTEM Team. As an AccessSTEM Team member, you will engage in experiences that will enhance your college and career success.

AccessSTEM Team Eligibility

High school or college students with disabilities are eligible to be AccessSTEM Team members. Priority is given to students who demonstrate an interest and aptitude in pursuing professional careers in science, technology, engineering, or mathematics fields. AccessSTEM Team members must have an email account and access to the Internet.

Participation Agreement

As a member of the AccessSTEM Team, you must actively communicate with AccessSTEM staff, peers, and mentors. To remain on the AccessSTEM Team and to be eligible for work-related opportunities, such as internships, you must be an "active participant." As an "active participant," you are expected to:

Log on to your email account at least once per week and read and respond to email messages.
Regularly communicate with your AccessSTEM mentoring group.
Attend AccessSTEM events when possible.
Notify AccessSTEM staff of any changes in your contact information, or your ability to participate in AccessSTEM internships and activities.

Application Requirements

Please contact DO-IT if you would like assistance in completing any portion of your application.

APPLICATION FORM
Complete the attached two-page AccessSTEM Team application form. This form must include a parent or guardian signature if you are under eighteen years of age.
PARAGRAPH
Submit a paragraph or two with your application explaining why you are interested in participating in an AccessSTEM internship and mentoring and how participation will help you reach your career goals. Include school honors, extracurricular and community activities, work-related experiences, and any other relevant information about yourself.
RECOMMENDATION
Submit one letter of recommendation from a teacher, faculty member, or someone who has worked with you closely or provide the name and contact information of a person that can provide a reference for you.
RESUME
Submit an up-to-date copy of your resume.

Submitting AccessSTEM Team Applications

Applications are accepted on an ongoing basis. The AccessSTEM Team application packet may be submitted via postal mail, fax, or email to the address below.

AccessSTEM Team Application Form

STUDENT DATA

Date: _____________

First name: _______________________

Last name: ________________________

Address:___________________________

City: _____________________________

State: _______

Zip: _________

Phone: _______________________

Email address: _________________________

Name and address of parent/guardian:

(if under 18)

______________________________________________

Parent email (if under 18): ______________________

Parent phone (if under 18): ______________________

Gender: ___________

Date of birth: ___________

Disability: ____________________________

Ethnicity (select one):

___ Hispanic or Latino

___ Not Hispanic or Latino

Race (select one or more):

___ American Indian/Alaska Native

___ Asian

___ White

___ Black or African American

___ Native Hawaiian/Pacific Islander

Veteran or military service:

___ Yes

___ No

Describe any accommodations that you may need to

participate in an internship:

______________________________________________

How did you hear about AccessSTEM?

___ Opportunities! Newsletter

___ other publication

___ email announcement

___ website

___ poster

___ presentation/meeting

___ friend (name) ________________________

___ other (name) ________________________

ACADEMIC BACKGROUND

Currently enrolled in:

____ High school

____ Community college

____ Tech college

____ Four-year university/college

School name: _________________________________

Anticipated graduation date: _________________

City/State: __________________________________

Major(s) (if applicable): ____________________

Current GPA: ____________________

Specific career interests: ___________________

EMPLOYMENT/INTERNSHIP INFORMATION

Citizenship (select one):

____ U.S. citizen

____ Permanent resident ("green card")

____ U.S. national (born in American Samoa/Swains Island
or descendant of U.S. national)

If not a U.S. citizen, do you have a right-to-work permit?
____ Yes ____ No

Where are you able to work in an internship
or other work-related experience?

Cities:_______________________________________

Publication Guidelines

Please note that, on occasion, AccessSTEM Team members are featured in DO-IT printed and web-based materials such as DO-IT News. As an AccessSTEM Team member, you agree to allow DO-IT and DO-IT project partners to publish information including, but not limited to, your first name, city and state of residence, name of school, employer, disability, and interests. This information may be used for program reporting and data analysis. As an AccessSTEM Team member, you also waive any right to inspect or approve the finished publication or the eventual use for which it might be applied. Although we will work with AccessSTEM members to plan and initiate disclosure of their disabilities to potential employers, schools, or other organizations in conjunction with AccessSTEM activities, your disability may be disclosed or implied.

Use of Photographs and Video

Some AccessSTEM events and work-related experiences are photographed and/or videotaped. When you participate in these activities you may be photographed and/or videotaped. As an AccessSTEM Team member, you agree to give DO-IT and DO-IT project partners permission to copyright, distribute, sell, broadcast, duplicate, exhibit and/or use film, photographs, and/or printed information without limitation for general education, information dissemination, and research purposes in videos, printed publications, and the Internet. In addition, you waive any right to inspect or approve the finished publication or other product in which your image/information might be used. Check here if you do not give permission to be included in pictures or videos.

I have read and agree to the expectations listed in the Participation Agreement, Publication Guidelines, and the Use of Photographs and Videotape guidelines as indicated above.

I understand DO-IT may request a criminal background check of program participants. I agree to report any past convictions to DO-IT at the time of application. Further, I agree to report to DO-IT any future charge or conviction at the time it occurs.

______________________________________________

Signature of AccessSTEM Team applicant

______________________________________________

Printed Name of applicant

For Applicants Under the Age of 18 Years

I give permission for my son/daughter to participate in AccessSTEM activities and events. I have read and agree to the above conditions, including the Participation Agreement expectations, Publication guidelines, and the Use of Photographs and Video guidelines as indicated above.



_____________________________________________      
Signature of Parent/Guardian 



_____________________________________________
Printed Name of Parent/Guardian

If you have questions about AccessSTEM or this application, please contact DO-IT at

206-685-DOIT (3648) — voice/TTY
888-972-DOIT (3648) — toll free voice/TTY,
206-221-4171 — FAX
doit@uw.edu.

Mail, fax, or email your completed application to

DO-IT
University of Washington
Box 354842
Seattle, WA 98195-4842
206-221-4171
doit@uw.edu