NASA student profile form

To finalize your funding from Washington Space Grant, please complete the student profile form below. NASA requires this information from all students who receive funding through its Space Grant program. You must complete this form (including a new media release form) every year that you receive WSGC funding.

As part of completing this profile form, you must also upload a completed copy of NASA’s media release form. The form is available as a PDF that you can fill out and sign electronically. Save a copy to your computer, then upload that when you arrive at the upload screen at the end of the profile form.

Download the media release form that is appropriate to your age. If you are currently under 18, you must have a parent or guardian complete the form with you.

• NASA media release form for adults
• NASA media release form for minors and their parents

About the student profile form

There are three pages to the form. The first page, as you can see below, covers your contact information as well as demographic information. These demographics questions are the standardized questions used by the U.S. federal government. We’re required to collect this information so that NASA can evaluate how well our program is meeting its goals.

Page two covers details about your specific award from Washington Space Grant, including what period your funding covers, how much your award amount is, and whether your award funded you in working on a research project.

Page three is where you will upload your completed media release form as a PDF. You will receive an on-screen confirmation once your form has been successfully submitted.

If you have any questions, please email us: nasa@uw.edu

NASA student profile form (for 2022–2023 & 2023–2024)

- Step 1 of 3

Which program are you part of? *

• Washington Space Grant
• Lunar Lava Tube Exploration Challenge (LLTEC)

Student information

Name -- First *

Name -- Middle *

Please provide a middle name or initial, if you have one. If you do not have a name that you'd consider a "middle" name, please enter N/A. We ask for this simply because it can help us differentiate between students with very similar names.

Name -- Last *

Preferred name

Birthdate *

MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Citizenship *

• United States citizen
• Non- United States citizen

Contact information

We use your mailing address to identify your congressional district (if you're a Washington state student). Congressional representatives love to know how many students from their districts received Space Grant support. Very occasionally we may need to mail something to you, but this is pretty rare.

Email -- Primary *

Email

Confirm Email

This email should be the address that you use regularly, so that the Washington Space Grant Consortium office can contact you if we have questions. This can be either your school address or a personal one.

Email -- Secondary *

Email

Confirm Email

This email should be a back-up address in case we can't reach you using your primary address. If you provided a school email address for your primary email above, please enter a non-school email here.

Phone *

Your current address -- Street line 1 *

Your current address -- Street line 2

Your current address -- City *

Your current address -- State *ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYASGUMPPRVI

Your current address -- Zip *

Is your permanent home address the same as above? *

• Yes
• No

Your permanent address -- Street line 1 *

Your permanent address -- Street line 2

Your permanent address -- City *

Your permanent address -- State *ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYASGUMPPRVI

Your permanent address -- Zip *

Demographic information

Gender identity *

• Woman
• Man
• Nonbinary
• Do not wish to report

Race *

• American Indian or Alaska Native
• Black or African American
• Asian
• Native Hawaiian or Other Pacific Islander
• White
• Do not wish to report

Ethnicity *

• Hispanic or Latino
• Not Hispanic or Latino
• Do not wish to report

Disability *

• I do not wish to identify my disability status
• I do not have a disability
• Hearing
• Vision
• Missing Extremities
• Paralysis
• Other impairments
• I have a disability, but it is not listed (please specify below)

Specify your disability if not listed above *

Have you served in a US military service? *

• Yes
• No

Are you a First-Generation student? *

• Yes
• No
• Do not wish to provide

A First-Generation student is someone whose parents did not receive a bachelor's degree. For finer clarification, we recommend the FAQ on this page: https://www.washington.edu/diversity/national-first-gen-day/

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Programmatic & award information -- Washington Space Grant participants

Programmatic & award information -- LLTEC participants

Your LLTEC team *EvCC - Win 2023A Triple ThreatArtemisiaAtomEMPOWERLunar LieutenantsLunar MinersLunarticosMegaMindsMoonwalkersOIT-Klamath Falls Lunar Rover TeamOrder of ChaosRover RoverSFCC/MESA-WA MCCP/UW AVELASpace GrantersStay HydratedTeam RockUW IndependentWoman Bosses

Your Space Grant institution *Bellevue CollegeCentral Washington UniversityEverett Community CollegeHeritage UniversityNorth Seattle CollegePeninsula CollegePierce College -- Fort SteilacoomSeattle Central CollegeUniversity of Puget SoundUniversity of WashingtonUniversity of Washington, BothellUniversity of Washington, TacomaWashington State UniversityWestern Washington UniversityWhitworth University

Other UW activities?

It's really helpful to know what other STEM activities you're involved in on campus. Please let us know above! Things like SEDS, EcoCAR, etc.

Your LLTEC institution *Georgia Institute of TechnologyEverett Community CollegeOregon Institution of TechnologyPierce CollegeSouth Puget Sound Community CollegeSpokane Falls Community CollegeUniversity of Texas at El PasoUniversity of Washington

Enrolled degree level *

• High school
• Associate's Degree
• Undergraduate -- First-Year
• Undergraduate -- Sophomore
• Undergraduate -- Junior
• Undergraduate -- Senior
• Master's Degree
• Ph.D.

This should be your enrolled degree level DURING YOUR AWARD PERIOD.

Enrolled major *

If you're a high school student, please put N/A.

Anticipated graduation date *

This is asking for your anticipated graduation from the enrolled degree level you selected above. We just need the month and the year (the exact date is not important). For example: June 2022.

What type of activity did your Space Grant funding support? *

• Academic year (ANY part of the academic year, whether your funding was for a full year or just for one term)
• Summer
• NASA internship
• Private industry internship
• Travel support
• Supply support

Which summer program? *

• SURP through the UW
• Summer program at my college

Which NASA center? *

Which industry partner? *

Award period *

• Full academic year (2021-2022)
• Partial academic year (autumn 2021)
• Partial academic year (winter/spring 2022)
• Summer 2022
• Full academic year (2022-2023)
• Partial academic year (autumn 2022)
• Partial academic year (winter/spring 2023)
• Summer 2023

What period does your Washington Space Grant funding support cover?

Award period -- Start *

What date does your award engagement start? We ask this because school terms vary across our Consortium.

Award period -- End *

What date does your award engagement end? We ask this because school terms vary across our Consortium.

Award amount *

Research support

Did your Washington Space Grant award fund you in doing research? *

• Yes
• No

SURP students -- please be sure you select YES to this question.

Mentor's name *

First

Last

Your mentor is the faculty of record for the project you worked on. Please do not list your TA here.

Mentor's email *

Mentor's phone

Mentor's institution & department *

This should be the college/university where your mentor is a faculty member and the academic department they're in. For example: University of Washington, Department of Earth and Space Sciences.

What is the title of your research project? *

No quotes necessary! Also -- if your project does not have a formal title just yet, please give a brief description.

When will your research project wrap up? *

An approximate date is fine!

Did you present your research anywhere? *

• Yes
• It's been submitted and is pending
• It's been accepted but not presented yet
• No

Has your research been published anywhere? *

• Yes
• It's been submitted and is pending
• It's been accepted but not published yet
• No

Please list all the authors on your research project *

Please use a Firstname Lastname format and separate all names with a comma.

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NASA media release form

Please upload your completed media release form.

NASA requires completed media forms from all students receiving funding through its Space Grant program, but Washington Space Grant Consortium respects that not everyone wants their face on social media.

Use of photos/videos on social media *

• YES -- I'm fine with Washington Space Grant potentially using my photos and/or videos on social media
• Please, no.

Your completed media release form *

Click or drag a file to this area to upload.

This form accepts PDFs only. If you're having problems saving and uploading the media release form in the proper format, please email us: nasa@uw.edu

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