MSFC 4606 Rover Intl Registration Form

International Registration Period MM/DD/YEAR - MM/DD/YEAR

NASA Human Exploration
Rover Challenge Home

Note: Only 4 teams per a country will be accepted.
**Quota of teams from these countries have been met: INDIA
MEXICO

Rover Registration Information
This form is to be completed by the team advisor or team lead. An
advisor serves as the primary contact and provides oversight of and
guidance to the team. A team lead serves as a secondary contact and
provides guidance, instruction, and leadership to the team.
Please note all fields must be completed in order to register.

School or University Name:

Address:

Address (cont):

City:
State/Territory:

Country:
listed contact us

*If your country is not

Postal Code:
School/University Type (e.g. High School, College):

Advisor/Instructor First, Last Name:

Advisor/Instructor Email Address: (e.g.:
[email protected])

Advisor phone number: (include area code)

Advisor FAX number: (include area code)

Advisor/Instructor T-Shirt Size:

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VISA Requirements
International participants in the NASA Rover Challenge
are responsible for obtaining their own Visas, and are
encouraged to do so as early as possible. For more
information on applying for a U.S. Visa, please visit:
http://travel.state.gov/visa/.
Your Team: (Provide the name, T-shirt size, and email
address for the team leader, and then list up to six
student participants along with T-shirt sizes.)
1. Team Leader
Name:

Shirt:

Email:
Students
2. Name:

Shirt:

3. Name:

Shirt:

4. Name:

Shirt:

5. Name:

Shirt:

6. Name:

Shirt:

Paperwork Reduction Act Statement
This information collection meets the requirements of 44
U.S.C § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of
Management and Budget (OMB) control number. The
OMB control number for this collection is 2700-0157 and
this information collection expires on MM/DD/YEAR. We
estimate that it will take 6 minutes to read the
instructions, gather the facts and answer the questions.
Send only comments relating to our time estimate to:
[email protected].
NASA Privacy Statement
This notice provides NASA's policy regarding the nature,
purpose, use and sharing of any information collected via
this form. The information you provide on this
NASA-issued form will be used only for its intended
purpose. NASA will protect your information consistent
with all applicable Federal laws, statutes,
Government-wide and NASA Policies and Procedural
Requirements. Submitting information is strictly
voluntary and, by doing so, you are giving NASA your

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permission to use the information for the specific
purpose of planning, coordinating, and conducting the
event. Additionally, the data collected is entered into
NASA's Office of Education Performance Management
system, and is used by Headquarters' staff to respond to
reporting requests from NASA management and others.
Data is/may be used in reporting to education leads in
sponsoring NASA mission directorates. If you do not
want to give NASA permission to use your information,
simply do not provide it. However, not providing the
requested information may result in NASA's inability to
provide you with the information or services you desire.
For additional details regarding NASA Privacy Policy and
Procedures, and other related information including
published NASA Privacy Impact Assessments (PIAs),
please visit the NASA Privacy Policy and Important
Notices Web site at http://www.nasa.gov/about
/highlights/HP_Privacy.html.
Would you like your email address made available
so your team can communicate with other Rover
Challenge teams?
Yes, I do
No, I don't
International Teams: Your team registration will
not be confirmed until the $100
registration/handling fee is paid.
All international teams will be charged a registration fee
of $95.00 (U.S.) per team registered plus a
nonrefundable $5.00 handling fee per team. The $95 fee
is reimbursable upon check-in at the challenge. Teams
that cancel their registration by the cancelation deadline
of MM/DD/YEAR, will be reimbursed. The registration fee
WILL NOT be reimbursed to teams that do not cancel
their registration by MM/DD/YEAR. Payment instructions
will be provided in the registration confirmation notice.
NASA Marshall Space Flight Center reserves the right
to verify applicant eligibility to participate in the 20XX
NASA Human Exploration Rover Challenge. Prior
participation in the Rover Challenge does not guarantee
applicant eligibility for the 20XX Rover Challenge.

MSFC Form 4606 (November 2012)

And finally, if you have registered and cannot
participate, please contact [NAME] at (256) [Phone
number] or via email at [email address].
THIS IS AN OFFICIAL NASA WEB PAGE

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NASA Contact: Jeff Ehmen
Project Manager: Diedra Williams
Curator: Susanna Litkenhous
NASA Privacy Statement | NASA Safety Reporting System

12/15/2016 7:15 AM