AccessSTEM Team Application

For high school, college, or graduate students with disabilities interested in STEM careers, mentoring, and internships.

The Alliance for Students with Disabilities in Science, Technology, Engineering, and Mathematics (AccessSTEM) is working to increase the number of people with disabilities in STEM careers. AccessSTEM is recruiting students who show interest and aptitude in STEM to become members of the AccessSTEM Team. Apply today!

AccessSTEM Team members

  • engage in an online community of peers and professionals that help guide students through transitions to college, graduate school, and employment
  • receive information about paid internships, research experiences, and other work-related opportunities
  • attend AccessSTEM events and activities
  • communicate with professionals in STEM fields

Eligibility

High school, college, or graduate students with disabilities in the United States are eligible to be AccessSTEM Team members. Priority is given to students who demonstrate an interest and aptitude in pursuing professional careers in STEM fields.

How to Apply

Submit the following by postal mail, fax, or email. Applications are accepted on an ongoing basis. Please contact us if you would like assistance in completing any portion of your application.

  1. Application Form and Participation Agreement
    Complete the attached forms, including parent or guardian signature(s) if you are under eighteen years of age.
  2. Paragraph
    Submit a paragraph with your application explaining why you are interested in participating in AccessSTEM, 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.
  3. Recommendation
    Submit one letter of recommendation from a teacher, faculty member, or someone who has worked with you closely.
  4. Resume
    Submit an up-to-date copy of your resume.

AccessSTEM Team Application

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:

______________________________________________

 

Are you currently enrolled in:
____ High school
____ Community college
____ Tech college
____ Four-year university/college
____ Graduate school

 

School name: _________________________________

Anticipated graduation date: _________________

City/State: __________________________________

Major(s) (if applicable): ____________________

Current GPA: ____________________

Specific career interests: ___________________

 

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:_______________________________________

How did you hear about AccessSTEM?
___ Opportunities! Newsletter
___ other publication
___ email announcement
___ website
___ poster
___ presentation/meeting
___ friend (name) ________________________
___ other (name) ________________________

Participation Agreement

As a member of AccessSTEM, you must actively communicate with AccessSTEM staff, peers, and mentors. AccessSTEM Team are expected to:

  • Log on to email at least once per week and read and respond to email messages.
  • Notify AccessSTEM staff of any changes in your contact information, or your ability to participate in AccessSTEM internships and activities.

Although we will work with AccessSTEM Team members to plan and initiate disclosure of disabilities to potential employers, schools, or other organizations in conjunction with AccessSTEM activities, your disability may be disclosed or implied.

DO-IT may request a criminal background check of program participants. Applicants must report any past convictions to DO-IT at the time of application and any further charge or conviction at the time it occurs.

 

______________________________________________

Signature of Participant

______________________________________________

Date

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.


______________________________________________

Printed Name of Parent/Guardian

______________________________________________

Signature of Parent/Guardian

______________________________________________

Date

Audio/Visual Release Agreement

I hereby agree to participate in the creation of media materials by DO-IT (Disabilities, Opportunities, Internetworking, and Technology) and by DO-IT project partners. I understand that various materials may be created from or associated with my participation in DO-IT events or programs, including the following (“Media Materials”):

  • Audio and/or video recordings with text transcripts or summaries
  • Photographs, including photographs of me
  • Biographical information about me including name, disability, age, interests, city and state of residence, and name of school.

To the extent I may own rights in the Media Materials, I hereby give permission in perpetuity and irrevocably to DO-IT to include the Media Materials in digital, print, or other projects (“Projects”). I understand and agree that including the Media Materials in the Projects means that they may be copied, distributed, displayed, and performed in various media, now known or later developed, including without limitation websites, print media, and exhibits. Except for the permission I am granting here, I retain ownership and all rights I may have in the Media Materials.

I understand and agree that I will receive no monetary payment for the permission I am granting in this Agreement. This Agreement expresses the complete understanding of the parties.

 

______________________________________________
Printed Name of Participant

______________________________________________
Signature of Participant

______________________________________________
Date

 

For participants under 18 years of age, please have a parent/guardian complete the following:

I hereby certify that I am the parent and/or guardian of the above participant. I agree to the above statement.

 

______________________________________________
Printed Name of Parent/Guardian

______________________________________________
Signature of Parent/Guardian

______________________________________________
Date

 

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