Youth Sign In Form
To be filled out by youth participating in NASA  program/services. Please know in advance that we thank you for completing this form. The information requested is used in evaluation processes for funding purposes.  It also assists the staff in providing quality educational programs. The Information will be held in the strictest confidence and identifying information will not be disseminated.
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Last Name
First Name
Age
Birth Sex
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Grade
Race/Ethnicity
What is your parent's email and/or phone number (if known)
Is it okay with your parent if we take your picture and put it on our website or use it in our publications?
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What is the activity or program you will be doing today?
AAP/EEO
 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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