Minnesota Space Grant Consortium (MnSGC): Student Information Form

Please enter information in all the fields below to the best of your ability. Responses to this questionnaire are confidential and will be reported to NASA in the Consortium’s annual report only in summary form.

Today's Date: U.S. Citizen: Note – MnSGC funding is limited to U.S. Citizens. Student ID#:
 No  Yes Proof of U.S. citizenship may be requested.

Student Name (Last, First, MI): MinnesotaCollege or University: Primary/Major Department:

Permanent/Home Address (Street, City, State, Zip): Date of Birth (unique identifier for NASA database):

Current/Student Address (Street, City, State, Zip): Current school e-mail address:
Other (non-school) e-mail address:

Demographic information (optional, but valuable to us for NASA reporting – will not be shared except in aggregate form)

Race (check as many as may apply):  American Indian or Alaska Native  Black or African American  Native Hawaiian or Pacific Islander  White  Asian  Some other race  Do not wish to provide

Ethnicity (check only one): Hispanic or Latino  Non-Hispanic or Not-Latino Do not wish to report

Gender: Student with disability: Are you (or siblings) first in family to graduate college? No  Yes
 Female  Male  No  Yes (Specify):Have you ever qualified for subsidized school lunches?  No  Yes

Currently pursuing Associate’s BA BS Overall Grade Point Average GPA (on a 4.0 scale) in primary
what type of degree? MA  MS Ph.D. (GPA) on a 4.0 scale: major (if available):

Faculty Advisor Term you enrolled at current school: e.g. Fall 2013
(name, dept, & e-mail): Anticipated final/graduation term at current school:

List ALL academic major(s) with primary major first: List ALL academic minor(s):

Areas of Study/Interest:
(select from list onp. 2) Primary: Secondary: Tertiary:

College degree(s) already held Were previous degree(s) obtained

(mostly for transfer and graduate while receiving MnSGC scholar-

students), in what field(s), from ship support?

what institution(s), awarded when?  No  Yes

Terminal Educational Goal: Bachelor's 2nd Bachelor's Master's 2nd Master's Ph.D. Postdoc

Describe how you plan to achieve the terminal education goal listed above and how long you expect it will take. e.g. "Finish my B.A. next spring (May 2015). Work in the aerospace industry for about 2 years. Return to school to earn a master's degree in 2 additional years."

Career Goals: After completing your studies, indicate which of the following areas you plan to work in? (select a maximum of three)
 Consulting Higher Education Military NASA Undecided
 Private Industry Administrative State/Local Government  Non-NASA Federal Agency
 Teaching (K-12) Faculty Non-Profit Organization Other (specify):

Additional Comments:

For MnSGC Use Only:

MnSGC record ID code: Grant year(s):

Participant in which MnSGC project?
Was this a paid position? No  YesIf yes:Date(s) of Stipend: Amount of Stipend:

Applicant for which MnSGC scholarship? e.g. local affiliate Space Grant scholarship vs. consortium-wide scholarship
Was this student an awardee? No  YesIf yes:Date of Award: Amount of Award:

Additional participation reports, scholarships, and/or general comments (continue on back of sheet if necessary):
1st step outside of your institution and e-mail for LT:

Areas of Study/Interest

MnSGC Basic Student Information Form – 7/2014

Physical Sciences

Astronomy

Astrophysics

Chemistry

Computer Science

Mathematics

Physical Sciences

Physics

Planetary Geoscience

Planetary Science

Life Sciences

Biology

Biochemistry

Botany

Health Science/ Nutrition

Life Sciences

Medicine/ Med. Research

Molecular/ Cell Biology

Zoology

Social Sciences

Anthropology

Architecture

Art

Economics

Education

History

Philosophy

Political Science/ Public Policy

Psychology

Social Sciences

Sociology

Earth Science

Atmospheric Science

Climatology/ Meteorology

Earth Sciences

Environmental Science

Geography

Geology

Geophysics

Oceanography

Engineering

Agricultural

Aeronautical/ Aerospace

Architectural

Bioengineering

Chemical

Civil

Computer

Electrical/ Electronic

Engineering Science

Engineering Mechanics

Environmental

Industrial

Materials Science/ Engineering

Mechanical

Mining/ Petroleum & Natural Gas

Nuclear

Other

Enter name of discipline on form

MnSGC Basic Student Information Form – 7/2014