Form MSFC 4605 MSFC 4605 Rover US Registration Form

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U.S. Registration Period MM/DD/YEAR - MM/DD/YEAR

NASA Human Exploration
Rover Challenge Home
Rover Registration Information

This form is to be completed by the team advisor or team lead. An advisor serves as the
primary contact and provides oversight of and guidance to the team. A team lead serves as a
secondary contact and provides guidance, instruction, and leadership to the team.
Please note all fields must be completed in order to register.

School or University Name:
Address:
Address (cont):
City:
State:

Zip:

-

(ex. 12345)

School/University Type (e.g. High School, College):
Advisor/Instructor First, Last Name:

Advisor/Instructor Email Address: (e.g.: you@osu.edu)

Advisor phone number: (include area code)

Advisor FAX number: (include area code)

Advisor/Instructor T-Shirt Size:

Your Team: (Provide the name, T-shirt size, and email address for the
team leader, and then list up to six student participants along with T-shirt
sizes.)
1. Team Leader
Name:

Shirt:

Email:
Students
2. Name:

Shirt:

3. Name:

Shirt:

4. Name:

Shirt:

5. Name:

Shirt:

6. Name:

Shirt:

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 (OMB) control number. The OMB control number

for this collection is 2700-0157 and this information collection expires on
MM/DD/YEAR. We estimate that it will take 6 minutes to read the
instructions, gather the facts and answer the questions. Send only
comments relating to our time estimate to:
HQ-OEIDAdmin1@mail.nasa.gov.
NASA Privacy Statement
This notice provides NASA's policy regarding the nature, purpose, use and
sharing of any information collected via this form. The information you
provide on this NASA-issued form will be used only for its intended
purpose. NASA will protect your information consistent with all applicable
Federal laws, statutes, Government-wide and NASA Policies and Procedural
Requirements. Submitting information is strictly voluntary and, by doing
so, you are giving NASA your permission to use the information for the
specific purpose of planning, coordinating, and conducting the event.
Additionally, the data collected is entered into NASA's Office of Education
Performance Management system, and is used by Headquarters' staff to
respond to reporting requests from NASA management and others. Data
is/may be used in reporting to education leads in sponsoring NASA mission
directorates. If you do not want to give NASA permission to use your
information, simply do not provide it. However, not providing the
requested information may result in NASA's inability to provide you with
the information or services you desire. For additional details regarding
NASA Privacy Policy and Procedures, and other related information
including published NASA Privacy Impact Assessments (PIAs), please visit
the NASA Privacy Policy and Important Notices Web site at
http://www.nasa.gov/about/highlights/HP_Privacy.html.
Would you like your email address made available so your team
can communicate with other Rover Challenge teams?
Yes, I do
No, I don't

NASA Marshall Space Flight Center reserves the right to verify
applicant eligibility to participate in the 20XX NASA Human Exploration
Rover Challenge. Prior participation in the Rover Challenge does not
guarantee applicant eligibility for the 20XX Rover Challenge.

MSFC Form 4605 (November 2012)

And finally, if you have registered and cannot participate, please contact
[name] at 256-[PHONE #] or via email at
[EMAIL ADDRESS].
THIS IS AN OFFICIAL NASA WEB PAGE
NASA Contact: Jeff Ehmen
Project Manager: Diedra Williams
Curator: Susanna Litkenhous
NASA Privacy Statement | NASA Safety Reporting System

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