NASA C-3071 Waiver of Compensation/Student Certification

National
Aeronautics and
Space
Administration

Waiver of Compensation/Student Certification
Dropping In a Microgravity Environment (DIME)
(Completion of form is required for processing of application.)

I understand that as a participant in the NASA Glenn DIME Program, I will not be
considered an employee of NASA Glenn Research Center. The purpose of my visit will be
to observe government research and development activities and use the Center facilities to
conduct educational research projects.
I waive and forever release the United States—for self, executor, administrator, heirs and
assigns—from any claim for wages, salary, or compensation of any kind that may be
connected with tasks or services that may be performed by me during my Center visit. I
understand and acknowledge that participation in the program does not entitle me to
unemployment compensation.
I certify, by my signature below, that I am a citizen of the United States of America and that
all information contained in this application is accurate and correct. I further understand and
agree that any misrepresentation or inaccurate information reported on my application will
be cause for disqualification for consideration and from participation in the DIME Program
and other NASA programs.
If selected to participate, I understand I must participate for the entire time allocated and
failure to do so or abide by the program safety and security policies and procedures could
result in termination and could be just cause for disqualification or consideration from future
program participation in the DIME Program and other NASA programs.
Print your full name below and sign and date for acceptance—the signature of a parent or
guardian is only required if student is under 18 years of age.

Student

Parent/Guardian

Print name

Print name

Signature

Signature

Date

Date
Telephone number where you can be reached during the day

NASA C-3071 (NOV 10)