ISGC Student Participant Form

ISGC Student Participant Form

First Name*

Middle Name

Last Name*

Preferred Name

Institution Comment Box

Student ID*

Type of Program*

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Project Name*

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Other: Project Name

Comment Box

Internship Location*

PI Name*

Select or enter value

Comment Box

Other PI Name

Start date for the project?*

What is your projected end date for this project?*

Demographic Data

NASA asks that we report consolidated demographic data on our program participants to show the impact of our programs. Please take a few minutes to fill out the following questions as completely as you can.

In addition, you will be receiving an invitation from NASA's Gateway system to register with NASA. We strongly suggest that you do so - as NASA is building this system to be able to connect you with future opportunities.

How did you hear about this opportunity?

Date of Birth*

Gender Comment Box

Ethnicity*

Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

Hispanic or Latinx

Non-Hispanic or Latinx

Do not wish to report

Disability*

Do you have a disability, based on the National Center of Educational Statistics' list of disabilities categories? (including difficulty hearing, seeing, or speaking, mobility limitations/orthopedic impairments, traumatic brain injury, specific learning disabilities, ADD or ADHD, Autism Spectrum Disorders, cognitive difficulties or intellectual disability, mental illness or psychiatric conditions)

Select or enter value

Disability Comment Box

Citizenship*

United States Citizen

Non-United States Citizen

Other (please specify in the comment box below)

Comment Box

Military Service*

Have you ever served in the United States Armed Forces?

Yes

First Generation Student

Are you a first generation student? (A first generation student is defined as someone who's parents or legal guardians did not earn a bachelor's degree or higher.)

Yes

Low Income Background

Do you come from a low income background? For a definition of “Low Income” please visit

https://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html

Yes

Hometown, State*

Current Street Address*

Current City*

Current Zip Code*

Current State*

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

If not, please fill out your permanent address below

Yes

Permanent Street Address

Permanent City

Permanent State

Permanent Zip Code

Permanent Country

Idaho Congressional District

(Use hometown or permanent address) Map for reference: https://www2.census.gov/geo/maps/cong_dist/cd117/st_based/CD117_ID.pdf

Select or enter value

School Email*

Alternate Email*

Once you leave school, we may want to contact you about ISGC alumni activities. To do so, we need a non-school email address.

LinkedIn URL

Add your LinkedIn profile page below.

Please join our network https://www.linkedin.com/company/nasa-idaho-space-grant-consortium/

If you're a student, consider also joining our student group here

Primary Phone*

Cell Phone

Are you being paid for your work related to this project?

Select or enter value

How much will you receive or have received? (total)

Comment Box

Major*

Minor (or area of emphasis)

Planned Graduation Date*

Have you participated in any of these STEM programs?

Select or enter value

Comment Box

Form Certification*

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

Release of information to public and congressional representatives*

By checking the box below, you authorize NASA ISGC and its affiliates to share information about you and your project with the public and Idaho's congressional representatives.

Release of information to NASA*

By checking the box below, you authorize NASA ISGC to share detailed information about you (e.g., demographic information) with NASA as needed.

Internship requirements: By checking the box below, you understand:

• You are required to submit a final report. The final report should be submitted once your internship is complete. The final report forms are available at https://www.idahospacegrant.org/student-forms

• Failure to submit required reports on time could affect your ability to receive further funding from ISGC.

• You agree to participate in an ISGC internship virtual internship meeting to present a brief summary of your internship.

• You agree to participate in longitudinal tracking related to your internship award. This means that you will receive occasional emails and other communications about your career progress during and after your internship award. We track this information to demonstrate the impact and effectiveness of the ISGC Internship program to NASA and Congress.

• You agree to comply with requests for information from ISGC and/or NASA including end-of-the-year surveys, etc.

• You agree to participate in any ISGC Intern events held at your institution. (You will be notified of events in advance.)

• You must credit NASA ISGC in all publications and/or activities related to this project. Please contact ISGC if you would like to request the ISGC logo for use on your publications/presentations.

• You must submit copies of all publications related to this research/activity to ISGC. An online form is available to do this on the ISGC website under https://www.idahospacegrant.org/student-forms

If you have not previously completed a W-9 form for the University of Idaho, you will need to do so in order to receive your stipend. Please fill out the w-9 at https://www.idahospacegrant.org/student-forms and upload the form below. (Please note: Although the W-9 form mentions sending the form to the State Controller's Office or SOC, please do NOT do so. Just upload it here, and we will take care of the rest.) If you would like to be paid via Direct Deposit, please fill out a Direct Deposit form also on the ISGC website at https://www.idahospacegrant.org/student-forms and upload it below.

I agree to the above ISGC Internship Requirements*

By checking the box below, you understand:

• You must be a U.S. citizen to receive an ISGC Fellowship.

• You must be a full-time student.

• You must attend an ISGC affiliate institution in the state of Idaho.

• You must be engaged in research in a science, technology, engineering, math, or science/math education discipline and making progress on the research plan outlined in your application.

• You must maintain a 3.5 GPA per semester.

I understand and comply with the requirements for this fellowship.

By checking the box below, you understand:

• You are required to submit a progress report and a final report. Your progress report should be submitted half-way through your fellowship period. The final report should be submitted once your fellowship is complete. The progress and final report forms are available at https://www.idahospacegrant.org/student-forms

• Failure to submit required reports on time could affect your ability to receive further funding from ISGC.

• You agree to participate in longitudinal tracking related to your fellowship award. This means that you will receive occasional emails and other communications about your career progress during and after your fellowship award. We track this information to demonstrate the impact and effectiveness of the ISGC Fellowship program to NASA and Congress.

• You agree to comply with requests for information from ISGC and/or NASA including end-of-the-year surveys, etc.

• You agree to attend any ISGC Fellow events held at your institution. (You will be notified of events in advance.)

• You must credit NASA ISGC in all publications and/or activities related to this project. Please contact ISGC to request the ISGC logo for use on your publications/presentations.

• In addition, any final peer-reviewed manuscripts that are the result of research conducted with NASA funds must be submitted to NASA's PubSpace repository through the NIH Manuscript Submission (NIHMS) system.

Please visit https://www.nasa.gov/open/researchaccess/pubspace for submission instructions.

I understand the reporting and publication requirements for this award

By checking the box below, you understand:

• The Idaho Space Grant Consortium Fellowship is a federally-funded grant program and all fellowships are contingent upon funding. Individuals accepting this award may not concurrently receive other federal fellowships or traineeships. The exception to this policy is Section 178(a) of Title 38, U.S. Code, which allows a student to receive concurrent educational benefits from the Department of Veterans Affairs.

• Failure to comply with the grant requirements listed above may result in termination of the fellowship and any related funding.

• If your GPA falls below a 3.5 in a semester, or you fail to report your research progress, you will be placed on probation and the ISGC may contact your research advisor to create a corrective action plan.

• You must notify ISGC if there are substantial changes to your research plan. The ISGC Director must approve any major changes to any fellowships research plans.

Please fill out a project change request form at https://www.idahospacegrant.org/student-forms for any of the following situations:

• Changes in research advisor;

• Award period extensions; and/or

• Major changes in project scope or focus.

I understand the compliance and project change requirements for this award.

Files To Upload*

Please use the space below to upload any of the following:

1. NASA Media Release: In the event that NASA likes your project and wants to share your story with the public, they need your permission to do so. Please fill out and sign this form, and then upload it below. The for is located at https://www.idahospacegrant.org/_files/ugd/0fc144_0fb66371103045f3912916da255d1884.pdf

2. If you feel comfortable, please upload a picture of yourself which we may share on our website and social media pages as student highlights.

Drag and drop files here or

Send me a copy of my responses

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