Oregon NASA Space Grant Consortium

First Name:
Middle Name:
Last Name:
e-mail:	sample-applicant@example.com
Alternate e-mail:
Verification of US Citizenship:	I am a citizen of the United States of America
Local Address:
	, 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
Permanent Address:
	, 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
Text messaging:	Send applications updates via text message
Cell Phone:
Alternate Phone:	( ) -
Birthdate:
Residency:	Oregon     Other

University:	What Oregon Space Grant University will you be attending in the Fall? Eastern Oregon University George Fox University Lane Community College Linn Benton Community College Oregon Coast Community College Oregon Institute of Technology Oregon State University Pacific University Portland Community College Portland State University Southern Oregon University Southwestern Oregon Community College University of Oregon University of Portland Western Oregon University
Class Standing:	Freshman Sophomore Junior Senior Masters Student PhD Student As of March 2024
Major:
Expected Date of Graduation:
Cumulative GPA:	(for all subjects, 4 point scale)
GPA within major:	(4 point scale)
Academic Transcript:	File Upload (PDF Format) An unofficial transcript printed from the student account of the college or university website is acceptable. If you are selected to receive this award, official transcripts may be required for verification.

Letter of Intent:	(Page limit: 2 pages) Includes the following: Describe the Plan of Study for your academic goals throughout your undergraduate program. Express your interest in and commitment to helping support OSGC's mission to create a STEM-literate fworkforce to support the space science/aerospace industry. Briefly describe your skill sets and qualifications in context of this opportunity. Describe how this opportunity relates to your current area of interest and how it would benefit you contribute to your academic objectives and future career goals. File Upload (PDF Format)
Student Resume:	(Page limit: 1 page) Include relevant employment, education, and extra-curricular activities. Resume should include current contact information including email, phone, and mailing address. File Upload (PDF Format)
Approach and Outreach Plan:	(Page limit: 2 pages) Includes the following: In coordination with OSGC leadership, ambassadors are expected to demonstrate self-directed efforts when connecting with local communities. Describe the approach you would take to meet the goals of serving as a Student Ambassador to engage with higher education, K-12 communities, and public audiences, with the intent of reaching students, families, and communities to promote STEM awareness and education to a diverse population. Elaborate on what forms of communication you plan to utilize. Provide specific examples of outreach activities and events you might plan and which organizations you might engage. File Upload (PDF Format)
DEIA Statement:	(Page limit: 1 page) Diversity, Equity, Inclusion, and Accessibility (DEIA) are top priorities for OSGC, NASA, and OSTEM. Please carefully review OSGC's DEIA efforts listed on the consortium website with links to guiding documents. Describe strategies and goals your approach and planned activities will include for supporting and enhancing diversity and inclusion. Provide specific plans for promoting events and activities and broadening the reach to underserved and underrepresented communities within your district. File Upload (PDF Format)
Timeline and Milestones:	(Page limit: 1 page) Timelines are tools that help ambassadors stay on track to complete a project within the allotted timeframe. Include a timeline for your student ambassadorship that includes milestones and measurable outcomes. The timeline will be a shared document with OSGC leadership as a guide to ensure project deadlines are met in a timely manner and within the period of performance. Refer to the Dates and Deadlines: Period of Performance section for associated deadlines. File Upload (PDF Format)
Affiliate Representative Statement of Support:	(See Program website for Fillable Form) Students must present their approach and outreach plan to the Affiliate Representative from the student's respective institution. The Affiliate Representative must provide a brief statement acknowledging support for the student's plan. The statement of support must express the Affiliate Representative's willingness to support the student's efforts, help make community connections whenever possible, and help facilitate outreach events/activities as needed. Affiliate Representatives are not be responsible for outreach events, tracking activities that have been completed by participants in the program, or managing the Student Ambassador. The statement of support does not indicate an endorsement of any one student for the position, merely that the Affiliate Representative has received, reviewed, and approved the Approach and Outreach Plan prepared by the applicant to the OSGC Student Ambassador Program. The statement of support does not serve as the required letter of recommendation. File Upload (PDF Format)
Letter of Recommendation:	One letter of recommendation is required. The letter should specifically address the student's qualifications and merit for receiving an OSGC Student Ambassadorship. Students will be asked to provide contact information for the person providing a letter of recommendation. Upon submission of your application, this individual will receive an email request for the letter from notices@spacegrant.net. The letter of recommendation will be due Friday, June 14, 2024. Name: Title: Institution: Phone: email: email confirm:

Gender:	Male Female Do not wish to report
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Do not wish to report
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
Person With Disability:	I do not have a disability I do not wish to identify my disability status Hearing Vision Missing Extremities Paralysis Other Impairments I have a disability, but it is not listed Specify if not listed:
Have you ever served in the U.S. military?	Yes No
	Where did you hear about this opportunity?

I certify that all information in this data sheet is true and complete to the best of my knowledge. I also authorize release of information as described in the program guidelines. I understand that submitting false information will disqualify me from participation in Oregon NASA Space Grant programs and opportunities.