LS-NSSA @UMR Registration Form_2022-24
For more information on the Louis Stokes-North Star STEM Alliance (LS-NSSA), the opportunities and funding the grant provides, and eligibility requirements, please see these slides and/or visit the LS-NSSA webpage. Any questions before or after completing this form, please contact Professor Ratliff-Crain at ratliffj@r.umn.edu. 

* NSSA-LSAMP/3-M-eligible students (Level I) are defined by the grant as (1) being in a STEM (Science, Technology, Engineering, Mathematics) major (BSHS counts); (2) interested in, or engaged in, STEM (not clinical) research; (3) and a US Citizen or permanent resident/Green Card holder in one of the following demographic groups:
  • Black or African American: A person having origins in any of the black racial groups of Africa.
  • American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
  • Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.
  • Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
  • Southeast Asian (inc. Brunei, Burma (Myanmar), Cambodia, Timor-Leste, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand and Vietnam)
  • Transfer student.

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Email *
I am... *
If eligible for Level I funding, I am would like to apply for:
Whether eligible for Level I funding, I would like to:
First Name *
Last Name *
Optional: Preferred Name (if different from above)
Gender *
Address *
Adress 2
City/Town *
State/Province *
ZIP/Postal Code *
Country *
Telephone *
School email *
Personal email
Student ID *
Expected Year of Graduation *
Major or Intended Major *
Required
GPA (if in first semester, enter 9.9) *
Are you a first-generation student? (First-generation defined as a student where neither parents/guardians have completed a 4-year college/university degree)
 *
Did you transfer to UMR from another college or university? *
If you are a transfer student, where did you transfer from and when?
Enrollment status *
Ethnicity *
Race (check all that apply) *
Required
If you chose Asian, please specify:
Citizenship *
Are you receiving financial aid (including grants, scholarships, subsidized loans) this academic year? *
Have you completed a Free Application for Federal Student Aid (FAFSA) for this academic year?
 *
Programs of Interest offered by the North Star STEM Alliance
 *
Required
Release Statement
I grant that my institution or the University of Minnesota may use excerpts of my reflections on participation in the Alliance programs in reports or promotional materials. I also grant that my institution or the University of Minnesota may use excerpts of my reflections on participation in the Alliance programs in reports or promotional materials. Lastly, the only identifying information associated with such excerpts may be class standing, major and institution.
Initial if you agree
 *
How this information will be used:
The information you submit on this form will be used by college/university officials and other Alliance administrators to evaluate your eligibility to become a scholar or peer mentor, evaluate program effectiveness, and report data to the National Science Foundation (NSF) for evaluation of overall program effectiveness. Please be assured that gender, race, ethnicity and disability status information will not affect your eligibility to become a scholar or peer mentor, but the NSF requires the collection of this information as a condition of program funding. As a scholar and/or peer mentor, information about your participation in program events will also be provided to the NSF at the end of the year, which is a prerequisite for you to be eligible for a stipend. If you wish to claim a stipend for your participation in the program, you will be required to submit your Social Security Number to a financial representative at your institution, in order to process the payment. Please contact your site coordinator if you have questions about the application process or information handling. By submitting this application, I certify that this information is complete and correct to the best of my knowledge. If I am accepted, I understand and agree to fully participate in activities sponsored by the North Star STEM Alliance. I understand that financial assistance is only awarded to students who are accepted and who meet the National Science Foundation-LSAMP eligibility requirements.
Initial if you agree
 *
Authorization for Photography
I hereby expressly grant that my institution or the University of Minnesota, lead institution of the North Star STEM Alliance, the right to make, use, and/or publish information, photographs, or any other reproduction of my physical likeness for various communication efforts such as pamphlets, booklets, video tapes, audiotapes, slide shows or internet sites. In addition, I expressly grant this right to be used for educational, marketing, and/or promotional purposes.
Initial if you agree
 *
A copy of your responses will be emailed to the address you provided.
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