DO-IT Pals Application

Applicant Information

Contact Information

First Name *

Last Name *

Pronouns

Pronouns that should be used to refer to you (optional):

Please specify pronouns

Address1 *

Address2

City *

State

Zipcode *

Country

Phone

Email *

Parent/Guardian Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Address1 *

Parent/Guardian Address2

Parent/Guardian City *

Parent/Guardian State

Parent/Guardian Zipcode *

Parent/Guardian Country

Parent/Guardian Phone

Parent/Guardian Email

School Information

School Name

School Location

Your Grade Level: *

Expected Date of High School Graduation

Biographical Information

Date of Birth *

Year

Month

Day

Gender

Ethnicity

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Disability *

Academic and other awards (if any)

Pals Application Questions

1. Please describe what your interest has been in science and mathematics courses.

2. Describe your educational and career goals. *

3. Please state in 100 words or less why you would like to be a DO-IT Pal.

4. What is your disability? How does it affect your ability to learn and/or complete classwork?

5. Do you have access to a computer regularly?

Do you have access to a computer regularly? radio button

Yes

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?

6. Do you have regular access to the Internet?

Do you have regular access to the Internet? Radio Button

Yes

If yes, please explain through which organization or service you have access. If no, explain how you plan to obtain access.

Additional Comments

Participation Agreement

As a DO-IT Pal, you are expected to:

Log on to the Internet at least once per week.
Regularly communicate with DO-IT Pals and Mentors.
Send an email message to the doitpals or doitchat list at least once every two weeks.
Send greetings to new DO-IT Pals, and other new participants when they are introduced online.
Use online resources in classes at school (for example, to obtain information to use in class papers, projects, or discussions).

By submitting this form, you agree to these terms. *

I agree

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