Student Profile Form
"
*
" indicates required fields
Personal Information
Name
*
First
Middle
Last
Gender
*
Female
Male
Do not wish to report
Race (select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Do not wish to report
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Do not wish to report
Disability (select all that apply)
*
I do not have a disability
I do not wish to identify my disability status
Vision
Hearing
Paralysis
Missing Extremities
Other Impairments
I have a disability, but it is not listed
Other Disability
Citizenship
*
United States Citizen
Non-United States Citizen
Have you served in the United States Armed Forces?
*
Yes
No
Date of Birth
*
MM slash DD slash YYYY
Please ensure that your birth year is correct.
Contact Information
School Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Permanent Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Email Account
*
Secondary Email Account
*
Cell Phone
*
Secondary Phone
Educational Information
College/University
*
Cameron University
East Central University
Langston University
Oklahoma State University
Redlands Community College
Southeastern Oklahoma State University
Southern Nazarene University
Southwestern Oklahoma State University
Tulsa Community College
University of Oklahoma
Major
*
Please use the full name of your major
Standing
*
Freshman
Sophomore
Junior
Senior
Masters Student
Doctoral Student
Expected Graduation Date
*
MM slash DD slash YYYY
Adviser Information
Did you have an academic or project adviser?
*
Yes
No
Adviser's Name
*
First
Last
Adviser's email
*
Adviser's Phone
*
Program Information
Program
*
Oklahoma Space Grant Scholarship
Oklahoma Space Grant Fellowship
Oklahoma Space Grant Internship
Oklahoma Space Grant Wages
STELLAR
Location
Location where you received the award (i.e. the NASA center/Company where you had your internships)
Name
This field is for validation purposes and should be left unchanged.