Which application are you applying to? Join LSAMP Student Reflection Travel Click here for the Photo Release form. Student Information First Name Last Name Middle Initial Gender Female Male Gender Variant/Non-Conforming Non-binary/Genderqueer Transgender Female Transgender Male Decline to Answer Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PrÃncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Telephone School Email Personal Email Student ID Join Century College LS-NSSA Expected Year of Graduation Major or Intended Major Agricultural Science Chemistry Computer Science Engineering Environmental Science Geosciences Life or Biological Sciences Mathematics and Statistics Physics or Astronomy Non-STEM STEM- Undeclared Other/Not Listed If you chose Other or Not Listed above, please indicate your current major or intended major. GPA Please report to two decimal places. Are you a first-generation student? (First-generation defined as a student where neither parents/guardians have completed a 4-year college/university degree) Yes No Are you a student who transferred? Yes No If you are a transfer student, where did you transfer from? Enrollment Status Full-time Part-time Ethnicity Hispanic or Latino Not Hispanic nor Latino Race White Black or African American Native American Alaska Native Native Hawaiian or Pacific Islander Asian Select all that apply. If you chose Asian, please specify. East Asian South Asian Southeast Asian Includes: Brunei, Burma (Myanmar), Cambodia, Timor-Leste, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, and Vietnam Other Citizenship US Citizen Permanent Resident Temporary Resident Have you completed a Free Application for Federal Student Aid (FAFSA) for this academic year? Yes No Programs of Interest offered by the North Star STEM Alliance Social Networking Undergraduate Research Leadership Opportunities Undergraduate Mentoring Graduate Mentorship Graduate School Preparation Study Groups Professional Development Other If you chose Other, please list what other programs of interest you are seeking. Release Statement I grant that my institution or the University of Minnesota may use excerpts of my reflections on participation in the Alliance programs in reports or promotional materials. I also grant that my institution or the University of Minnesota may use excerpts of my reflections on participation in the Alliance programs in reports or promotional materials. Lastly, the only identifying information associated with such excerpts may be class standing, major and institution. How this information will be used. The information you submit on this form will be used by college/university officials and other Alliance administrators to evaluate your eligibility to become a scholar or peer mentor, evaluate program effectiveness, and report data to the National Science Foundation (NSF) for evaluation of overall program effectiveness. Please be assured that gender, race, ethnicity and disability status information will not affect your eligibility to become a scholar or peer mentor, but the NSF requires the collection of this information as a condition of program funding. As a scholar and/or peer mentor, information about your participation in program events will also be provided to the NSF at the end of the year, which is a prerequisite for you to be eligible for a stipend. If you wish to claim a stipend for your participation in the program, you will be required to submit your Social Security Number to a financial representative at your institution, in order to process the payment. Please contact your site coordinator if you have questions about the application process or information handling. By submitting this application, I certify that this information is complete and correct to the best of my knowledge. If I am accepted, I understand and agree to fully participate in activities sponsored by the North Star STEM Alliance. I understand that financial assistance is only awarded to students who are accepted and who meet the National Science Foundation-LSAMP eligibility requirements. Authorization for Photography I hereby expressly grant that my institution or the University of Minnesota, lead institution of the North Star STEM Alliance, the right to make, use, and/or publish information, photographs, or any other reproduction of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes, audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be used for educational, marketing, and/or promotional purposes. Student Reflection Travel Reflections Only Event Title Event Dates Event Location Organization All Submissions Reflections Approximately 450-750 words. I grant that the North Star STEM Alliance may use excerpts of my reflections in reports or promotional materials; the only identifying information associated with such excerpts may be class standing, major, and institution. By submitting this reflection, I certify that this information is complete and correct to the best of my knowledge. Travel Expected Graduation Year Have you submitted a scholar application with the North Star STEM Alliance? Yes No Event, program, or conference name Event Location Dates of Travel Airfare Hotel Registration Other Costs Total Amount Requested Do you have other sources of funding? Yes No Please list sources and amounts Is your travel experience affiliated with any of the following? Research abroad programs Departmental or Industry host Courses affiliated with experience Involves research Professional conference: Attendee Presenter Competitor What will you accomplish? How does it advance your academic career? Please explain in 75-100 words. If you accept travel support from the North Star STEM Alliance you are required to commit to at least 5 hours of service and outreach once you return. I understand that if I do not complete my commitment, my student account may be charged for expenses covered by the North Star STEM Alliance. I also grant that my institution or the University of Minnesota may use excerpts of my reflections on participation in the Alliance programs in reports or promotional materials. Lastly, the only identifying information associated with such excerpts may be class standing, major and institution. How this information will be used. The information you submit on this form will be used by college/university officials and other Alliance administrators to evaluate your eligibility to become a scholar or peer mentor, evaluate program effectiveness, and report data to the National Science Foundation (NSF) for evaluation of overall program effectiveness. Please be assured that gender, race, ethnicity and disability status information will not affect your eligibility to become a scholar or peer mentor, but the NSF requires the collection of this information as a condition of program funding. By submitting this application, I certify that this information is complete and correct to the best of my knowledge. If I am accepted, I understand and agree to fully participate in activities sponsored by the North Star STEM Alliance. I understand that financial assistance is only awarded to students who are accepted and who meet the National Science Foundation-LSAMP eligibility requirements. Leave this field blank