Vertical Mentoring Workshop for the Blind - STEM
Participant Application
You are encouraged to submit your application by February 28, 2006. Applications
received after that date will be reviewed on a space-available basis. If you have questions
about the workshop or this form, please contact VMWB-STEM at 206-616-9056 or via
email: vmwb@cs.washington.edu.
First name:______________________ Last name:___________________________
Address:____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Phone number:_______________________________________________________
Dietary and/or accessibility needs: _______________________________________
_____________________________________________________________
Are you under 18 (required)?____________________________________________
If a student, your current school: _________________________________________
If in high school, your planned college major: ______________________________
If in college, your current or planned major: ________________________________
If in grad school, your field of study: ______________________________________
If in grad school, years completed: ________________________________________
If a working professional, highest degree attained: ___________________________
Place of employment: ____________________________________________
Years in the workforce: ___________________________________________
Please describe your interest and/or participation in science, math, engineering as part of
your education or work experience.
Please state in one hundred words or less why you would like to be included in the
Vertical Mentoring Workshop for the Blind.
Please suggest possible breakout session topics. Indicate if you are willing to lead a
breakout session.
Send completed forms to
VMWS-STEM
c/o Kay Beck-Benton
Box 352350
University of Washington
Seattle, WA 98195