Iowa Space Grant Consortium Student Participation Form

Iowa Space Grant Consortium Student Participation Form

Thank you for taking the time to complete this student participation form for ISGC! We report to NASA the impact our program has on Iowa students, the state, and STEM fields.

Please also complete the Photo Authorization and Release Form for ISGC.

We appreciate your time in completing these forms! Good luck on your project/award!

What year are you participating in this project?*

Select

First Name*

Middle Name/Initial

Last Name*

Today's Date*

Are you a U.S. Citizen?*

Yes

Student University ID No.*

Overall GPA*

X.XX

Date of Birth*

Base Programs:

Drake University

1. Biomarkers for Radiation-Induced DNA Damage during Human Space Exploration

PI: Dr. Pramod Mahajan

2. Conceptual Design and Study of a Mangeto-Ionization Radiation Shield and Artificial Gravity System for Interplanetary Travel – The MISSFIT Collaboration

PI: Dr. Athanasios Petridis

Iowa State University

1. Nanomaterials for Advanced Manufacturing and Aeronautics (NAMA)

PI: Dr. Shan Jiang

2. Examining Aerospace Engineering Students’ Learning Experiences

PI: Professor Matthew Nelson

University of Iowa

Infrastructure for Data-Advanced Research and Education (I-DARE) to improve NASA’s Earth Science applications in Iowa

PI: Dr. Jun Wang

University of Northern Iowa

Wind Cave as a Terrestrial Analog for Possible Exobiological Environments off Earth

PI: Dr. Joshua Sebree

Student Experiential Hands-On Project:

Select only if you are part of a team that was funded for a student team hands-on project through the ISGC annual competition https://www.iaspacegrant.org/2023-24-sho/

If you are not 100% sure, please contact your project lead or mentor. This ensures our reporting database remains accurate.

Program or project name*

If you have selected more than one ISGC program above please specify and provide the Program or Project name for each ISGC program selected.

Name of project research advisor for this program:*

Faculty Mentor (PI) name (a.k.a who gave this link) (not the "participant" filling this form)

SHO Participants: Faculty (PI) that is mentoring your team, not your project lead

Interns: Please list your NASA/hosting organization mentor

Your role in the project:*

Select or enter value

Current Address:

Street*

City*

State*

Select or enter value

Zip*

Cell Phone

Phone

University Email*

Is your current address the same as your permanent address?*

If no, please provide permanent address below.

Yes

Street*

City*

State*

Zip*

Country, if different than U.S.

Personal Email*

Years at this level

Field of Study*

Academic Advisor

Please include email address after name.

Expected Graduation Month*

Select

Expected Graduation Year*

Select

Please list all currently held degrees.

Date obtained

Final Education Goal*

BS/BA

MS/MA

PhD

Field of Study for Final Degree*

After completing studies, please check final career goal(s) from list below.*

Select

Other

NASA STEM Gateway

Do you have a profile on the NASA STEM Gateway System? https://stemgateway.nasa.gov/s/

What is NASA STEM Gateway? - On this site, you’ll find current available NASA opportunities in the areas of internships, challenges, research, educator professional development, and Pre-college and College STEM experiences.

Please note that NASA Gateway does not have ISGC opportunities posted at this time. Stay tuned! - this does not affect your current involvement with the Iowa Space Grant Consortium.

Select or enter value

Gateway Profile Email

Please provide the email that you have your NASA STEM Gateway profile under.

Demographics

Please complete the following to self-report demographics for NASA data collection and reporting systems.

NASA's goal in advancing equity, in line with President Biden's Executive Order, is to provide everyone with the opportunity to reach their full potential. This includes efforts to remove systemic barriers to and provide equal access to opportunities and benefits, identify communities the Federal Government has underserved, and develop policies designed to advance equity for those communities.

Sex

Please indicate which sex was assigned to you on your birth certificate.

Male

Female

Do you identify as a member of the LGBTQ+ community?

Yes

Prefer not to say

Ethnicity

Hispanic

Non-Hispanic

Prefer not to say

Race

Please check which best describes you: (You may select more than one.)

First Generation

Are you the first person to attend college in your immediate family?

Yes

Prefer not to say

Did you grow up in a rural community?

Rural is defined as a population of <2,500.

Yes

Prefer not to say

Does your family household qualify as low-income?

For a definition of “Low Income” please visit https://www.ed.gov/about/ed-offices/ope/trio/federal-trio-programs-current-year-low-income-levels

Yes

Prefer not to say

U.S. Military Service

Yes

Prefer not to say

Do you have a documented disability?

Yes

Prefer not to say

Are you a member of a religious minority in the U.S.?

Yes

Prefer not to say

Form Certification*

By checking the box below, you certify that the information you provide in this form is complete and accurate.

Send me a copy of my responses

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