Student Membership Application Form

OPTIONAL STUDENT MEMBERSHIP APPLICATION SUPPORTING SIGNATURES

THIS IS FOR CHAPTER ADVISORS ONLY – Applications are not Sent to NSTEM

Directions:

1. Fill out the information requested in Parts 1-3
2. Have your parent/guardian review and sign the Membership Authorization in Part 4 if you are below the age of 18, or sign it yourself if you are 18 or over
3. If required by your Chapter, obtain the supporting signatures of teachers/advisors on a Student Membership – Supporting Signature Form that will be provided by the Chapter Advisor
4. Return the above to your Chapter Advisor
5. Information noted by an asterisk must be provided

The mission of the National STEM Honor Society^TM (NSTEM^TM) is to inspire innovation and recognize student excellence from Pre-K to Career^TM in the fields of science, technology, engineering, and mathematics (STEM). NSTEM does so by encouraging project-based learning, recognizing student achievement, and creating opportunities for mutually beneficial collaboration among students, schools, communities, and businesses in the STEM fields.

To become a student member of your local NSTEM chapter: 

1. Fill out the information requested in Parts 1-3.
2. Have your parent/guardian review and sign the Membership Authorization in Part 4 if you are below the age of 18, or sign it yourself if you are 18 or over.
3. Return this application to your Chapter Advisor.

Information noted by an asterisk must be provided.

PART 1. APPLICANT INFORMATION
Applicant Full Name*: _______________________________________________________________
Applicant Email*: ___________________________________________________________________
Name of School*: ___________________________________________________________________
Current Grade Level*: _________________
Is Applicant 13 Years Old or Above?* ____ Yes ___No
Why are you interested in becoming a member of NSTEM and what STEM related activities do you engage in both in and out of school?
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PART 2. PARENT/GUARDIAN INFORMATION Parent/Guardian information is important so that parents/guardians can receive (a) login information which permits parents/guardians to access the student portions of the NSTEM website, and (b) copies of the NSTEM electronic newsletters and emails that are sent to student members age 13 and over.
Parent/Guardian 1 Name*: ___________________________________________________________
Parent/Guardian 1 Email*: ___________________________________________________________
Parent/Guardian 1 Phone: ___________________________________________________________
Parent/Guardian 2 Name: ___________________________________________________________
Parent/Guardian 2 Email: ___________________________________________________________
Parent/Guardian 2 Phone: ___________________________________________________________

PART 3. DEMOGRAPHIC INFORMATION – OPTIONAL We understand that these may be sensitive questions, and respect your right not to provide this information. If you answer the questions, the Chapter Advisor will combine your answers with those of the other members and provide the information to NSTEM only as part of a single aggregate number. The information provided to NSTEM will not be linked to you in any way. NSTEM uses this aggregated anonymized data to assist NSTEM in determining how to best serve members as they pursue their futures in STEM, and in applying for grant funding for our scholarships and awards .
Do you qualify for free or reduced school lunch? ❑ Yes ❑ No
Gender: ❑ Female ❑ Male ❑ Other
With which racial or ethnic categories do you identify?
❑ Black or African American ❑ Asian/Pacific Islander ❑ Hispanic/Latino ❑ Native Hawaiian
❑ Caucasian (not Latino/Hispanic) ❑ Native American or Alaskan Native
❑ Other: ____________________________________________________

PART 4. MEMBERSHIP AUTHORIZATION*:
Name of Applicant: _____________________________________________National STEM Honor Society (NSTEM) requires that the following Membership Authorization be signed by a parent/guardian if the Applicant is under the age of 18, or by the Applicant if 18 or over. If this Membership Authorization is not signed, or is signed but is modified, the Applicant will not be eligible to be a member of NSTEM.
If the Applicant is under the age of 13, the parent/guardian may withdraw consent at any time to NSTEM collecting personal data of the Applicant via the internet and using such data by contacting NSTEM. In such case, the Applicant will not be able to continue as a student member of NSTEM.

I am the (check one):

❑ the parent or guardian of the Applicant

❑ the Applicant In such capacity, I certify that I have reviewed the information provided in the completed application form, and hereby:

1. consent to the Applicant participating as a student member in the National STEM Honor Society(NSTEM) and providing the information in this application to NSTEM;
2. grant to NSTEM, the Chapter Advisor, and other persons acting for or through NSTEM, the right to collect personal information about the Applicant, via the internet or otherwise, and if applicable share it with NSTEM for use by NSTEM in the operation of the NSTEM program as further described in the NSTEM Privacy Policy; and
3. authorize NSTEM to send me electronic copies of the NSTEM newsletters and emails, and acknowledge that I can unsubscribe from receiving them at any time. I hereby assume full legal responsibility for the consents and authorizations given above.

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Signature of Applicant or Parent/Guardian Date