Direct Participant Form
Must Choose One of The Following:
*
RESEARCH INFRASTRUCTURE: worked as an assistant to a faculty member’s project/research
HIGHER EDUCATION: worked as an assistant or team member during a workshop/program or faculty grant, or student on Quadcopter Challenge
STUDENT PROJECT/TRAVEL: worked in collaboration or traveled with a group of students
Your Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Current Institution
*
Central Connecticut State University
Eastern Connecticut State University
Fairfield University
Southern Connecticut State University
Trinity College
University of Bridgeport
University of Connecticut
University of New Haven
University of Hartford
Wesleyan University
Yale University
Asnuntuck Community College
Capital Community College
Housatonic Community College
Manchester Community College
Middlesex Community College
Naugatuck Valley Community College
Northwestern Connecticut Community College
Norwalk Community College
Quinebaug Valley Community College
Tunxis Community College
Three Rivers Community College
Project Title
*
PI/Project Leader's Name
*
First Name
Last Name
Proposed Period of Performance
*
Institution where project took place
*
Central Connecticut State Univeristy
Eastern Connecticut State University
Fairfield University
Southern Connecticut State University
Trinity College
Universtiy of Bridgeport
University of Connecticut
University of New Haven
University of Hartford
Wesleyan University
Yale University
Asnuntuck Community College
Capital Community College
Housatonic Community College
Manchester Community College
Middlesex Community College
Naugatuck Valley Community College
Northwestern Connecticut Community College
Norwalk Community College
Quinebaug Valley Community College
Three Rivers Community College
Tunxis Community College
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Official School Email Address
*
example@example.com
Alternate Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Gender
*
Male
Female
Do not wish to report
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Do Not Wish To Report
Race
*
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Black or African American
Asian
White
Do Not Wish To Provide
Enrollment Status (during period of performance):
*
Undergraduate
Graduate
Disability?
*
Yes
No
Please Elaborate
*
Are You a U.S. Citizen?
*
Yes
No
Are You a First Generation College Student?
*
Yes
No
Have You Served in the United States Military?
*
Yes
No
Have you attended the Grants Expo for this award?
*
Yes
No
What year did you attend the Expo?
*
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Longitudinal Tracking
Expected Graduation Date for Current Degree Requirements (I.e. Associate's, Bachelor's, Master's, PhD, etc)
*
-
Month
-
Day
Year
Date
Institution
*
Degree Pursuing
*
Area of Study
*
Your Next Step: Please select the appropriate category. Indicate where or to what company/institution your next professional and/or academic step will take you. NOTE: If you just completed your Associate's Degree at a community college and are pursuing your Bachelor's Degree, select "Graduated and Pursuing Advanced Degree Requirements".
*
Still Enrolled in Current Degree Requirements
Graduated and Pursuing Advanced Degree
Post-Graduation Employment
Employment Type
*
Seeking STEM Employment
Employed in STEM (Aerospace) Position
Employed by NASA/JPL
Employed in STEM Academic Field
Employed in K-12 STEM Academic Field
Non-STEM Employment
Employed in STEM (non-Aerospace) Position
Place of Employment (if employed)
*
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