NASA MAA Application Form Note that space is limited. Student Information Session In-person summer 2023 Session starts July 10 – July 27, 2023 (Monday through Thursday, 9 am to noon). K1-12 grades will be served. Student Last name First name Middle initial Permanent home address Apt. no. City State ZIP code Date of birth School district School name Gender Female Male X Grade K1-2 K3-4 K5-6 K7-8 K9-12 Grade in the begining of the semester selected Has the student previously attended MAA? yes no If yes, how many previous sessions? Has this student participated in any other NASA sponsored activity? yes no Check all that apply Amateur Radio on the International Space Station (ISS) Contest/competitions (e.g., FIRST Robotics, Great Moonbuggy Race, Exploring Space Challenge, etc.) Distance learning activities through the Digital Learning Network (DLN) Interdisciplinary National Science Program Incorporating Research and Education Experience (INSPIRE) ISS EarthKAM Mars Student Imaging Project (MSIP) MATHCOUNTS NASA Explorer Schools (NES) NASA Shadowing/Mentoring Activities and Internships Reduced Gravity Student Flight Opportunities Program (specify activity) Other (list any other programs, projects, or activities) Parent Information Parent/guardian last name Parent/guardian first name Telephone no. Alternate telephone no. Permanent e-mail address Alternate e-mail address Emergency Contact Emergency contact (other than parent) full name Relationship to student Emergency contact Telephone no. Emergency contact Alternate telephone no. Donation Help Support the Program (Optional) Benefactor: $300 Sponsor: $150 Supporter: $50 Other: $ A matching donation will be provided by my employer (name): The operational costs of this program are roughly $150 per student, but through generous donations and grants, we are able to offer it to our community free of charge. If you would like to make a tax-deductible donation to the York College MAA program, please indicate the level of your support below and attach a check made out to MAA @York College/RFCUNY. Donations are strictly voluntary and will not be used when considering this application. We accept corporate matching gifts as well. To recommend MAA to your organization for a larger contribution, please contact the directors. We accept donations at any time. A letter for tax purposes acknowledging your donation will be sent to the student’s home address. Other donation If you selected other please enter amount here. Or, If you selected matching donation by employer please provide name here. Notice Please submit the completed application using this online form. Any optional donation should be addressed to: MAA @ York College/RFCUNY, 94-20 Guy R. Brewer Blvd., Jamaica, NY 11451. For more information, please use nasamaa@york.cuny.edu Other To determine which members of each ethnic/racial group are reached by this program, NASA requests the information below. Submission of this information is VOLUNTARY and will not be used when considering this application. Student ethnic background American Indian/Alaska Native Asian Black/African-American Hispanic/Latino(a) Native Hawaiian/Pacific Islander White (Non-Hispanic) Other (check appropriate box) Does the student qualify for free or reduced price lunch? yes no How did you hear about MAA? Classroom visit Flyer/brochure Magazine Newspaper Radio Religious Institution Student’s school Television Word of mouth Other (please specify) (check all that apply) If you selected other please specify here Consent I have read, understand and accept the above statement. I do not consent I (Parent/Guardian), do hereby release and discharge the York College MAA site, members, administrators and agents from any and all claims, present and future, known and unknown, due to, or arising in any manner from, this child’s participation in the project or related activities sponsored by York College MAA. I have read or someone from the York College MAA site has read and explained the information contained in this form to me. I willingly agree and give my consent to let York College MAA enter data about my child and me into its computer information system. I hereby grant York College MAA and others acting on its behalf, the right to record my child and his/her voice using audio, photographic, video, or other such techniques; to include my child’s name, likeness, voice and biographical material in connection with these recordings; to use, reproduce, distribute, and exhibit such recordings in any and all media throughout the world without limitation; and to authorize others to do so, for any purpose which York College MAA and those acting pursuant to its authority, deem appropriate. I hereby waive all rights of any nature in such recording(s) and the exhibition thereof. It is understood that this grant is provided at no cost and that no compensation of any kind shall be due or expected. Parent/guardian Signature (Type your full name) I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about the student. Submit Reset
