North Carolina Space Grant

First Name:
Last Name:
e-mail:	sample-applicant@example.com
Alternate e-mail:
Address:
	CityState , AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   - ZIP Code +4 Lookup ZipcodeZipcode +4
Congressional District:	District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 District 10 District 11 District 12 District 13 To find your Congressional District visit the House of Representatives Website. If your permanent home address is out of state please choose the congressional district for your school.
U.S. Citizenship/Residency:	I am a citizen of the United States of America I am a permanent resident of the United States of America I am neither a citizen or permanent resident of the United States of America

Each participant must be recommended by a school administrator who is willing to verify that the candidate: A) is someone who has the potential to be a leader among teaching peers; B) will have a viable opportunity and the necessary school system support to offer one or more space science-related professional development workshops to local and/or regional colleagues; C) will support the release time for the NC Space Education Ambassador to attend the professional development at NASA Langley and the Bridging the Gap Conference.

Please give the name (and email) of the school administrator who will be writing you a recommendation.

	Principal/Administrator
Name:
Title:
Phone:
email:
email confirm:

Once you have submitted your application we will email them 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. The deadline for submission of reference letters is Friday, July 7, 2023.

Grades You Currently Teach:
Subjects You Currently Teach:
Your Current Position/Title:
School:
Address:	Address Line 2
City:
State and Zipcode:	State AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zipcode
Phone:
Fax:
School email:
School District:
School Type (check all that apply):	Public   Private   Charter   Urban   Rural

What is your formal education and teaching experience? (degree, years taught, etc.) (250 word limit) What is your current assignment? (Describe job responsibilities and other related duties) (500 word limit) List professional activities. (In-service participation, membership in professional organizations, number of workshops taught and audience (500 word limit) Other teacher-related activities. (Education outreach activities in the community, youth programs, etc.) (500 word limit) Tell your school story including demographics of the student population and community. (500 word limit) Describe a meaningful STEM learning experience your students have engaged in that impacted your school and community. (500 word limit) Explain how you will engage other educators and organizations if selected as a NC Space Education Ambassador? (500 word limit) How would participating in the NC Space Education Ambassadors Program impact you and the educators in your school, district and region? How will this program impact you as a leader within your school district and region? (500 word limit) for reporting purposes only

Gender:	Male Female
Ethnicity:	Hispanic or Latino Not Hispanic or Latino
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Do not wish to report
Birthdate:
Person With Disability:	I do not have a disability I have a disability I choose not to disclose
Birthdate:
	How did you hear about the NC Space Education Ambassadors (NCSEA)?

If I receive this award I will:

• Participate in webinars, including a series of NASA professional development modules. These virtual experiences will be led by NASA Educational Specialists from various NASA centers via virtual platforms. 1-2 webinar sessions will be hosted per month (September 2023 through May 2024) on Tuesdays from 6:00-7:00 pm
• Complete lessons that compliment NASA content and share best practices during webinar sessions.
• Complete two dissemination activities in their respective districts to include: (1) one NASA professional development workshop, and (2) one NASA STEM Engagement opportunity for students.
• Attend a group field trip to NASA Langley Research Center in June 2024 (schedule dependent upon NASA Langley availability). NC Space Grant will cover all travel expenses.

I certify the information in this application is accurate to the best of my knowledge.