KEEP Application Form

Kennedy Educational Experiences Program (KEEP)

Program Description

The KEEP is a job shadowing program intended to provide students with career exploration under the mentorship of a Kennedy Space Center (KSC) NASA, or contractor employee.

Program Goal

Shadowing offers students an opportunity to explore career possibilities available at KSC under the guidance of a KSC mentor. Students are provided with information about various careers, career paths, and KSC educational resources and programs. Students will depart from KSC with knowledge that will be of value to them in career decision making and an awareness of additional educational opportunities and resources at KSC.

As NASA moves forward to fulfill The Vision for Space Exploration, KSC is focusing on efforts related to Exploration Systems. You are encouraged to visit the KSC home page to learn more about our launch and landing activities and educational programs at http://www.nasa.gov/centers/kennedy/about/index.html

Eligibility Requirements

Must be a U.S. citizen

Must be at least16 years of age

Student must be able to drive themselves onto KSC.

Students must be recommended for a job shadowing opportunity by a teacher, guidance counselor, or other school official. Daily schedules will be determined by the employee who the student will be mentored by.

Students are required to adhere to all safety, security and program guidelines.

How to Apply

Students must be recommended for a job shadowing opportunity by a teacher, guidance counselor, or other school official. Student requests will be accepted on a first-come, first-served basis. Application packages must be complete for consideration. Students must complete and return application and forms. Incomplete applications will not be considered.

Shadowing placements are dependent upon the availability of appropriate mentors and facilities. The Education Programs Office cannot guarantee a shadowing opportunity and will not sign any forms that state one is guaranteed. Each session has limited placement and shadowing days.

Placements cannot be made without the signature of a parent or guardian (if applicable) and recommending school official.

Additional information can be obtained by contacting the following:

Rose M. Austin

Education Specialist

NASA-KSC Education Programs

& University Research Division

Phone: 321-867-6481

Fax: 321-867-2097

E-mail: rose.m.austin@nasa.gov

Kennedy Educational Experience Program (KEEP)

Application

(To be completed by Applicant. Please TYPE or PRINT)

1. PERSONAL AND BACKGROUND INFORMATION

	Last Name		First Name				MI
U.S. Citizen Yes No Note: If U.S. citizen and born outside of the U.S. or Puerto Rico, you must provide the information and documentation requested below prior to your job shadowing start date. Naturalization no. _____________________ Expiration Date (if any) ____________
MAILING ADDRESS
Street		City			State	Zip
Email Address		Telephone
SCHOOL INFORMATION
Name
Street		City			State	Zip
Name of Guidance/Career Counselor/Teacher		Telephone
Email Address:
ACADEMIC INFORMATION
Current Academic Level
Freshman Sophomore Junior Senior
Cumulative GPA out of 4.0				Expected Graduation Date

C. PLACEMENT INFORMATION

Please check the field of study in which you would like to shadow. If choosing more than one discipline, indicate order of preference by numbering 1 through 3, with 1 being your first choice. Final student placement is determined by the mentor’s assignment request.

____ Aerospace/Aeronautics Engineering ____Materials Engineering

____Biological Science ____Mathematics

____Biomedical ____Metallurgy

____Chemical Engineering ____Mechanical Engineering

____Chemistry ____Physical Science

____Computer Engineering/Science ____Physics

____Electrical Engineering ____Propulsion Engineering

____Environmental Engineering/Science ____Structural Engineering

____Industrial Engineering ____Systems Engineering

____Other (be specific)_____________________________

Have you previously participated in a NASA program? Yes No (If no, skip to next section) If yes, please write the name of the program you participated in, the Center/School affiliated with the program and year of participation.

Program Name ___________________________________________

Center/School Name ______________________________________

Year(s) Participated ____________________________

D. PARENTAL CONSENT AND AUTHORIZATION: (Applicant and parent or guardian (when applicable) must sign below to be eligible. Unsigned applications will not be considered).

As a part of the application process, I certify that:

• I grant permission for two teachers, guidance counselor and/or career counselor selected by my son/daughter to complete the Teacher Recommendation Forms.

If selected for the above-mentioned program, I certify by my signature below, that:

• I give permission for my son/daughter to participate in the KEEP Program and all program related activities;

• I also authorize NASA to use any photographs that may be taken during the program for promotion activities

(i.e., Web site, newsletter, and promotional materials); and

• I authorize NASA to release my child’s name and address to educational organizations so he/she can be provided information on other student opportunities, scholarships, and educational programs.

I affirm that all of the information on this application is true and complete to the best of my knowledge. I certify that I am a U.S. citizen and meet all eligibility requirements as specified in the internship requirements. I understand that application materials become the property of NASA and cannot be returned. I hereby authorize NASA to utilize information about my application and my likeness for public relations purposes, publicity, or other educational opportunities.

I understand that as a participant in the NASA-KSC Education Experience Program (KEEP), I am a volunteer. I will not be considered a Federal employee of NASA-Kennedy Space Center. I agree that I will not receive any compensation, pay, or other benefits and that my service is not creditable for leave or any other benefits. I understand and acknowledge that participation in the program does not entitle me to unemployment compensation.

I agree to follow all applicable Federal laws and regulations and NASA directives, instructions, policies, procedures and requirements. I further agree to exercise due care when using Government property and to protect and preserve Government property.

Emergency Contact: __________________________

( ) ( )

Relationship Telephone No. Mobile No.

Student’s Signature Date

Parent’s/Guardian’s Signature of Consent Date

Teacher/guidance/Career counselor Recommendation - 1 - Science, Mathematics, or Computer Science -
Student’s Name:
Teacher’s Name/Position/Discipline:
Name of School:
How long have you known the student? In what capacity?
Please rate the student in the following areas.
1. Ability to follow rules and directions Always follows Sometimes follows Seldom follows Never follows		2. Accepts responsibility Always accepts responsibility Usually accepts responsibility Sometimes irresponsible Often irresponsible			3. Leadership ability Strong leadership ability Sometimes exhibits leadership Seldom exhibits leadership Always follows others
4. Initiative/Independence Seeks extra tasks Prepares assigned tasks Needs occasional reminders Needs constant reminding Seldom shows initiative		5. Ability to work well with others Always works well Sometimes works well Seldom works well Does not work well			6. Oral communication skills Very articulate Articulate Somewhat articulate Difficulty in articulation Inarticulate
7. Written Communication Excellent writing skills Good writing skills Average writing skills Poor writing skills	8. Level of interest Exhibits high interest Often interested Seldom interested Lacks interest			9. Motivation Highly self-motivated Sometimes motivated Seldom motivated Lacks motivation		10. Maturity Always exhibits maturity Sometimes exhibits maturity Seldom exhibits maturity Immature
Identify the strengths and skills that will most promote this student’s success in our Program: (check all that apply)
Oral Communication Leadership Skills Written Communication Career Awareness				Time Management Interpersonal Skills Research Technique Computer/Technology
Overall Recommendation for the Program Very Highly Recommended (top 5%) Highly Recommended (top 10%) Recommended Recommended with reservations Not Recommended		Teacher Comments:
Signature:________________________________________________________________						Date:___________________
May we contact you for additional information?	Yes No		Telephone No. (_____)_____________________			E-mail:_________________
This form should be returned as part of the student’s application package

Note: Two recommendations are required using the forms provided. The recommendations must be from the applicant’s teacher of science, math, or computer science, and/or Guidance/Career Counselor. Please have the teacher return the recommendation to the student in a sealed envelope with the teacher’s signature written across the seal.

Teacher/Guidance/Career counselor Recommendation - 2 - Science, Mathematics, or Computer Science -
Student’s Name:
Teacher’s Name/Position/Discipline:
Name of School:
How long have you known the student? In what capacity?
Please rate the student in the following areas.
1. Ability to follow rules and directions Always follows Sometimes follows Seldom follows Never follows		2. Accepts responsibility Always accepts responsibility Usually accepts responsibility Sometimes irresponsible Often irresponsible			3. Leadership ability Strong leadership ability Sometimes exhibits leadership Seldom exhibits leadership Always follows others
4. Initiative/Independence Seeks extra tasks Prepares assigned tasks Needs occasional reminders Needs constant reminding Seldom shows initiative		5. Ability to work well with others Always works well Sometimes works well Seldom works well Does not work well			6. Oral communication skills Very articulate Articulate Somewhat articulate Difficulty in articulation Inarticulate
7. Written Communication Excellent writing skills Good writing skills Average writing skills Poor writing skills	8. Level of interest Exhibits high interest Often interested Seldom interested Lacks interest			9. Motivation Highly self-motivated Sometimes motivated Seldom motivated Lacks motivation		10. Maturity Always exhibits maturity Sometimes exhibits maturity Seldom exhibits maturity Immature
Identify the strengths and skills that will most promote this student’s success in our Program: (check all that apply)
Oral Communication Leadership Skills Written Communication Career Awareness				Time Management Interpersonal Skills Research Technique Computer/Technology
Overall Recommendation for the Program Very Highly Recommended (top 5%) Highly Recommended (top 10%) Recommended Recommended with reservations Not Recommended		Teacher Comments:
Signature:________________________________________________________________						Date:___________________
May we contact you for additional information?	Yes No		Telephone No. (_____)_____________________			E-mail:_________________
This form should be returned as part of the student’s application package

Note: Two recommendations are required using the forms provided. The recommendations must be from the applicant’s teacher of science, math, or computer science, and/or Guidance/Career Counselor. Please have the teacher return the recommendation to the student in a sealed envelope with the teacher’s signature written across the seal.

APPLICATION PACKAGE INSTRUCTIONS

Before submitting this application, you should read it thoroughly. Special attention should be given to eligibility requirements, dates, and deadlines. Ensure you have supplied all information and materials requested. You are encouraged to keep a copy of your completed application package, as we are unable to return any application materials submitted for the program.

All five (5) of the items listed below must be submitted together with your KEEP Application:

___ Personal/Background Information (Page 2, Section A)

___ Academic Information (Page 2, Section B)

___ Placement Information (Page 3, Section C)

___ Parental Consent and Authorization Form (Page 4, Section D)

___ 2 Teacher/Guidance/Career Counselor Recommendations (Pages 5 & 6)

SPECIAL INSTRUCTIONS FOR SUBMISSION OF APPLICATIONS.

1. Applications will not be processed unless they are complete and all materials have been received.

2. An incomplete application package will not be considered.

3. Assignments are made based upon the information provided in the application and availability of mentors.

Questions related to KEEP may be sent by e-mail (please note KEEP in the subject line) to: rose.m.austin@nasa.gov, or by phone at 321.867.6481.

Retain these instructions for your information and mail the completed application package, including all required documentation to:

National Aeronautics and Space Administration

John F. Kennedy Space Center

Mail Code: EX-E

Attn: Rose M. Austin

Kennedy Space Center, FL 32899

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 60 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO THE ADDRESS LISTED ABOVE. Please call 321-867-6481 for additional information on this program. You may also send comments on our time estimate above to the address listed.

Privacy Act Notice

14 CFR 1212.602 - 10SPER

(1) Disclosure of information is voluntary;

(2) The intended use is to record application and participation in the NASA Education Program;

(3) The routine uses are as published in 72 FR 55828-55829 and as replicated on KSC Form 50-164 NS (PA).

(4) NASA will process application using the information provided herewith. Incomplete application will not be considered.

KSC Form 50-158 NS (PA) (OM) (01/11) OM 2700-0135 (7/2011)