Oregon Space Grant Student Profile Form
Confidential

Thank you for completing this Oregon Space Grant Student Profile Form. We are collecting this information because NASA, the agency that provided the funds for the program in which you participated, requires that we longitudinally track participants of our programs. NASA is interested in how your participation in programs impacts your progress though your education and careers. Be assured that any information that you provide here will be held in the strictest of confidence and not shared with anyone except NASA, our sponsor.

Personal Information:
First Name:
Middle Name:
Last Name:
Gender:Male Female Do not wich to report
Race: Select all that apply:
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
Ethnicity:
Disability:
I do not have a disability
I do not wish to identify my disability status
Vision
Hearing
Paralysis
Missing Extremities
Other Impairments
I have a disability, but it is not listed
  Specify if not listed:
Military Service:Have you ever served in the U.S. military?
Yes No
Birthday:
Contact Information:
Current Address:
City:
State: Zip:
Permanent Address:
City:
State: Zip:
Primary Email Account:
Secondary Email Account:
Cell Phone Number:
Secondary Phone Number:
Educational Information:
College/University: Please use the full name of the institution
Major: Please use the full name of your major
Standing:
Anticipated Graduation Date:
Please provide contact information for your academic or project advisor. If you do not have an academic advisor please leave this section blank
Advisor's Full Name:
Advisor's email:
Program:
Please indicate the Oregon Space Grant in which you participated.
Program:
Year:
Location: If other than your college/university