MSFC 4607 Rover Student Data Form

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NASA Human Exploration Rover Challenge ®
College Student Data Form
Each student team member must complete/submit this form in order to participate in the event.
*Required Fields.
Advisor Name:

NASA Human Exploration
Rover Challenge Home

School:

Team Name:

*Last Name:

*First Name:

School Address:

Zip:

*Middle
State

City:
Country:

USA

Phone

Participant Characteristics:
*Gender:

Male

Ethnicity (check one):

Female
Hispanic or Latino

*U.S. Citizen:

Yes

No

Not Hispanic or Latino

Race (check all that apply):
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian
White
Black or African American
Please specify any special physical, medical, or dietary needs you have to enable NASA to provide proper facilities, services and nutrition. (300 characters)

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 3.5 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 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.

MSFC Form 4607 (November 2012)

Previous Versions Obsolete

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