WVSU CASTEM- NASA AEL               Application-Beckley Site
To be filled out by parent/guardian for each child/student (PK-12th grade) that wishes consideration in NASA  program/services while in attendance at an existing in school or after school program. Please know in advance that we thank you for completing this form. The application information requested is used in evaluation processes for funding purposes.  It also assists the staff in providing quality educational programs. The application Information will be held in the strictest confidence and identifying information will not be disseminated.
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Email *
Date *
Student Last Name *
Student First Name *
Permanent Home Address and Apartment Number (if applicable) *
City *
State *
Zipcode *
Age of Student *
Gender *
Name of School or Program *
County *
Academic Level as of current school year *
Allow youth to use 3rd party software applications *
Parent/Guardian Last Name *
Parent/Guardian First Name *
Telephone Number *
Parent/Guardian Email Address *
Emergency Contact *
Please list last name, first name
Student Ethnic Background
I, Parent/Guardian do hereby release and discharge West Virginia State University (WVSU) and its staff members from claims arising from my child's participation in the project or related activities. I have read or have had someone read and explain the information contained in this form to me. I willingly agree and give my consent to let WVSU to enter data about my child and me into its computer information system. I hereby grant to WVSU and others acting on its behalf, the right to record my child and his/her voice using audio, photographic, video or other such techniques; to include my child's name, likeness, voice and biographical material in connection with these recordings; to use, reproduce, distribute and exhibit such recordings in any and all media through the world without limitation; and to authorize others to do so, for any purpose which WVSU and those acting pursuant to its authority; deem appropriate. *
I hereby waive all rights of any nature in such recordin(s) and the exhibition thereof. It is understood that this grant is provided at no cost to the Government and that no compensation of any kind shall be due or expected *
In case of an emergency, consent is granted to the staff of WVSU to provide medical service through the appropriate medical facility(ies) and or medical service provider(s) to my child listed on this application. *
Parent/Guardian  Name/Signature *
Please type your e-signature into the text box below
Date of Submission *
 West Virginia State University is an equal opportunity affirmative action institution. No person shall be denied admission to educational program, activities or employment on the basis of any legally protected status, or be subjected to prohibited discrimination involving, but not limited to, such factors as race, color, creed, religion, national or ethnic origin, marital status, citizenship, sex, sexual orientation, gender identity or expression, age, disability, or protected veteran status. Upon request, reasonable accommodations will be made to provide this content into an alternate accessible format. Please contact Carla Boggess at (304) 766-4278 or sayreca@wvstateu.edu.Concerns and complaints related to bias or equal opportunity in education and in employment based on aspects of diversity protected under federal, state, and local law, or arising under Title IX should be directed to: Carolyn Stuart, EEO Officer, at (304) 204-4018.Women, minorities, people with disabilities and veterans are encouraged to apply. 
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