MSFC 4605 (REVISED Rover US Registration Form

U.S. Registration Period MM/DD/YYYY - MM/DD/YYYY

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.

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School or University Name:

Address:

Address (cont):

City:

State:      Zip:   -   (ex. 12345)

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:

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:

Additional Team Members: (Provide the names of up to nine additional student team members. T-shirts and lunch will not be provided for these additional team members.)

Students

7. Name:  

8. Name:  

9. Name:  

10. Name: 

11. Name: 

12. Name: 

13. Name: 

14. Name: 

15. Name: 

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 07/31/2020. 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 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

 

      

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MSFC Form 4605 (September 2017)

And finally, if you have registered and cannot participate, please contact [NAME] at [phone number] or via email at email.