Student Profile - Community of Practice

PROFILE

Dear Student:

Please fill out the following form as completely as you can. NASA requires that we provide detailed information on each NASA funded activity. Completion of this form is required at the beginning of your participation in this project. This data helps us determine how well we're doing in reaching a diverse group of interested participants. Your responses are not shared outside the Nevada System of Higher Education except with NASA.

If you have any questions, you may contact Stephanie Borene, Program Coordinator, at stephanie_borene@nshe.nevada.edu or Alice Ward, Project Administrator at alice_ward@nshe.nevada.edu.

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* 1. Name:

First:

Last:

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* 2. Current educational insitution(s) you are attending:

CSN

GBC

WNC

TMCC

Other (please specify)

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* 3. Student ID (NSHE #):

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* 4. Gender:

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* 5. Race:

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* 6. Ethnicity:

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* 7. Disability:

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* 8. Are you a veteran of the U.S. armed forces?

Yes

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* 9. Citizenship:

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* 10. Date of Birth:

Date:

Date

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* 11. Current Address:

Address

City

State

ZIP

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* 12. Permanent Address (If above address is temporary):

Address

City

State

ZIP

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* 13. Email:

Primary Email Account:

Secondary Email Account:

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* 14. Phone:

Primary Phone Number:

Cell Phone Number:

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* 15. What is the most recent degree you have obtained?

High School Diploma

GED

Associates Degree

Bachelor's Degree

Master's Degree

Doctoral Degree

Other (please specify)

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* 16. If you have recently received a degree, please provide the month/year received and the degree field/ area of focus (i.e. May 2013, Microbiology. If you have not received a degree, please respond n/a or none.)

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* 17. How did you hear about the Community of Practice program?

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* 18. What is the amount of funding (such as scholarships) you will receive for this semester?

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* 19. What semester are you participating in?

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* 20. Number of credits enrolled in for participating semester:

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* 21. What is the degree major you are or were enrolled in during this NASA COP (Community of Practice) program:

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* 22. Grade Level:

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* 23. Are you currently (or have you been) engaged in any research projects? (If yes, please describe) We would like to know if this program has had a significant impact on your education/career plans.

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* 24. Anticipated graduation date:

Date:

Date

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* 25. What degree will you have attained at the time of graduation?

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* 26. What are your education or career goals for after graduation?

Attain a higher degree (BS)

Attain a higher degree (MS)

Attain a higher degree (PhD)

Work in my degree field

Work for NASA or a NASA Center

Other (please specify)

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* 27. Will you be attending a different educational institution next year? (If so, which one? What will your major be?)

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* 28. Space Grant Award History:

I have received an award from Space Grant before.

I have NOT received an award from Space Grant before.

If yes, please describe the type and amount of award:

FACULTY MENTOR INFORMATION:

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* 29. Faculty Mentor Information:

First Name:

Last Name:

Department:

Institution:

Email:

Phone: