Building Leaders for Advancing Science and Technology Chaperone

Please Note: This is a sample application for viewing purposes only. To apply to this program please visit the application "New User Registration" page and register with the system.

Applications Due: Saturday, February 1, 2025

The position for which you are applying will potentially require a background check, fingerprinting, and/or an online safety module as a condition of employment.

Personal Information

First Name:
Middle Name:
Last Name:
Preferred Name:
e-mail:	sample-applicant@example.com
Home Address:
	, VA
Home Phone:	( ) -
Work Phone:	( ) -
Cell Phone:	( ) -
Are you a US Citizen or Legal Permanent Resident?	Yes No
Are you a Virginia Resident?	Yes No
Gender:	MaleFemale

School Information

School Name:
School Address:
	, VA
Teaching License:	I hold a valid Virginia Professional Teaching License. Yes No List Endorsement areas: List subjects currently teaching:
Resume:	File Upload (PDF format only) If you do not have a PDF conversion tool you can use one of these free on-line PDF converters: PDF Online - PDF Converter. To ensure that your PDF files may be properly included in your application, please ensure that they are not protected via encryption, a password, a signed certificate, or in any other manner.

Recommendation Letters

As part of your application packet, you are required to provide two letters of recommendation from current or former supervisors, department chairs, school administrators or someone who can attest to your professional qualifications. Incomplete applications will not be considered.

	Reference #1
Name:
Title:
Institution:
Phone:
email:
email confirm:

Reference #2

Once you have submitted your application, the system will email these people instructions on how to submit an on-line letter of recommendation on your behalf. Please inform them that they will be receiving an email from notices@spacegrant.net with these instructions.

Note: It is the responsibility of the applicant to follow up with these people to ensure the recommendation is submitted electronically by the Saturday, February 8, 2025 deadline.

Session Preference

Please rank your session preferences by selecting from the options below. Note that if you only select one session, you will only be considered for that session.

Session	1st Choice	2nd Choice	3rd Choice	4th Choice	5th Choice	Not Interested in this Session
William & Mary June 22-25, 2025
Virginia Tech July 20-23, 2025
Radford University July 20-23, 2025
Old Dominion University July 27-30, 2025
University of Virginia August 3-6, 2025

Other Information

How did you hear about the Building Leaders for Advancing Science and Technology Program?

Do you expect to be employed as a consultant with any ODU program during the 2025 calendar year? Yes No

Please name and briefly describe your role:

Are you employed as a Master Teacher for any other VSGC program? Yes No

Which program (s)?
Virginia Space Coast Scholars
Virginia Aerospace and Technology Scholars
Virginia Earth System Science Scholars

Please describe why you are interested in being a Chaperone for BLAST. Include one or more ways your participation as a Chaperone may support your professional development.
(750 words or less)

Please describe your experiences in facilitating activities beyond the classroom for 8th and/or 9th grade students, such as field trips, extracurricular activities, and/or summer camps
(750 words or less)

Optional Information

Applicants are strongly encouraged to provide the information requested below. This information is collected for federal reporting purposes only.

Ethnicity:
Race:	American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Do not wish to report
Disability:	Yes No What in-person physical accommodations are needed for your disability?

Certification

I certify that all the information contained in this application is complete and correct and that I meet all the eligibility requirements stated in this application.

I understand that there is extensive walking at each BLAST session and that I could be walking approximately 5 miles per day.

Please Note: This is a sample application for viewing purposes only. To apply to this program please visit the application "New User Registration" page and register with the system.