CT SPACE GRANT COLLEGE CONSORTIUM
Out-of-State/Non-CT Cover Sheet
Helicopter/UAS Workshop: June 14-19, 2015 @ CCSU, New Britain, CT
In Collaboration with NC Space Grant
Application to be submitted by Friday, April 23, 2015
The information provided in this form will be used to help the CT Space Grant in their awarding
selection review process.
Complete student application will consist of:
1.
2.
3.
4.
5.
Out-of-State Helicopter/UAS Workshop Cover Sheet
Narrative: please see page 2 of cover sheet for more information
Resume: include Clubs and Engineering Association Memberships
One Letter of Recommendation
Student Transcript
6.
Primary Investigator (PI)
Name: ☐ Mr. ☐ Ms. ☐ Mrs.
School/State Space Grant
Major
Permanent Address:
☐ I will have completed at least 2 semesters of an engineering/related program by summer 2015
☐ US Citizen/ at least 18 years of age
Year of Expected Graduation:
Cell Phone & Home Phone:
Email:
________________________ ____
Signature
__ ______
_____________ ______________
Date
CT SPACE GRANT COLLEGE CONSORTIUM
203 Dana Hall, University of Hartford (Lead Institution)
200 Bloomfield Avenue, West Hartford, CT 06117
860-768-4813 [email protected] www.ctspacegrant.org
Institutional Certification
☐
Signatures below certify that the applicant’s state space grant approves of this
application and acknowledges an understanding that if this proposal is awarded, your
state space grant consortium will pay the associated invoice for your participation in this
workshop.
_______________________________________
_________________________
Signature (State Space Grant Office)
Date
Please Print Name
_______________________________________
Advisor Signature
_________________________
Date
Please Print Name
Additional Information from the Workshop Program Director:
Award Opportunities – This opportunity provides participants with a classroom instruction and
hands-on opportunity to learn more about why helicopters behave as they do during flight
operations. Workshop participants will also receive instruction on Unmanned Aircraft Systems,
UAS. Students will be capable of calibrating, setting up and programming UAS followed by
actually flying UAS. Workshop participants will also flight test radio controlled coaxial
helicopters, and VTOL aircraft that they build. Students will tour Sikorsky Aircraft and KAMAN
Aerospace, manufacturing and engineering facilities, and experience a 20 minute ride in a
Robertson 4-place, or equivalent, helicopter (up to 3,000 ft. and 140 mph) during this unique
training experience. Transportation, lodging and food are included in the fee.
As part of your application narrative, please answer the following questions:



How this workshop will enhance/contribute to your long-term academic and career
goals – one paragraph
What is the purpose of a helicopter tail rotor?
Explain the purpose of the K-max helicopter
Please provide the contact information for your state Space Grant Program Coordinator:
_________________________
Program Coordinator
____________________
E-mail Address
__________________
Phone Number
_________________________
Lead Institution
__________________________________________
Address
CT SPACE GRANT COLLEGE CONSORTIUM
203 Dana Hall, University of Hartford (Lead Institution)
200 Bloomfield Avenue, West Hartford, CT 06117
860-768-4813 [email protected] www.ctspacegrant.org
Important Reminder:
U.S. Citizenship is a requirement of eligibility for all CT Space Grant College Consortium awards.
Award recipients must bring proof of U.S. Citizenship in the form of one of the following (photocopy is acceptable): U.S. Passport
(expired or unexpired); Citizenship Certificate; Naturalization Certificate; Birth Certificate; Military or Company ID Card that Shows
Citizenship; or Certified Letter from some other organization that has verified citizenship.
Emergency Contact:
Name
Cell Phone
Relationship to You
Do you plan to stay in
campus housing during the
Workshop?
If yes, please complete the CCSU liability forms
below.
☐Small ☐Medium ☐ Large ☐X-Large ☐XX-Large ☐XXX-Large
T-Shirt Size
Will you require transportation
from/to Bradley International Airport,
Amtrak or the Union Bus Station?
If so, please provide your travel
date/time/carrier information.
Do you have any special dietary
restrictions/requirements that we
should know about?
What to Bring:
Valid Photo I.D. - Tours to Sikorsky Aircraft will require you to provide a current photo I.D. and proof in
advance of your U.S. Citizenship. Please remember to bring your I.D. with you to the Workshop.
Resume – You will have an opportunity to network with helicopter industry leaders during your attendance. It
is recommended that you have a copy of your resume available.
For those staying in the CCSU dorms:
Fan – The rooms are not air-conditioned, and New England weather can be unpredictable, so we recommend
bringing a small fan.
Linens – CCSU will provide, but you may wish to bring linens/towels with you.
CT SPACE GRANT COLLEGE CONSORTIUM
203 Dana Hall, University of Hartford (Lead Institution)
200 Bloomfield Avenue, West Hartford, CT 06117
860-768-4813 [email protected] www.ctspacegrant.org
ASSUMPTION OF RISK AND RELEASE
Participant Information:
First Name:
Street Address:
City:
Last Name:
State:
M.I.:
Zip:
I,
, am eighteen years of age or older and acknowledge that I intend to
participate in the Connecticut Space Grant Consortium sponsored Rotary Wing Engineering
Helicopter Workshop summer training program (“Activity”) at Central Connecticut State
University (CCSU), 1615 Stanley Street, New Britain, CT. 06050 from June 14 - 19, 2015.
I recognize that there are risks and hazards directly or inherently involved in the Activity and that I
may become injured during my participation. With full knowledge of the facts and circumstances
surrounding this Activity, I voluntarily understand this Activity and assume all responsibility and risk
from my participation in this Activity, including all risk of loss or limb or life, property damage, injury
to others, and other hazards to me.
I assure officials of CCSU that I have adequate health insurance necessary to provide for and pay any
medical costs that may directly or indirectly result from my participation in this Activity and that I will
indemnify and hold harmless CCSU and its employees and agents for any injury, including loss of limb
or life, of any person(s) and for any property damage caused by my negligence or intentional act or
omission.
I hereby release CCSU and its employees and agents from any liability whatsoever arising out of my
participation in this Activity, including but not limited to, any damage to my property or the property
of others and/or injury to myself or to others, including loss of limb or life, resulting from my
negligence or the negligence of CCSU and its employees and agents.
I assure CCSU that there are no health-related reasons or problems that preclude or restrict my
participation in this Activity.
The foregoing is submitted in consideration of CCSU allowing me to participate in this Activity. I
execute this document with full knowledge of the contents and consequences stated in this Release.
Participant Certification
Signature:
Printed Name:
Date:
Witness Certification
Signature:
Printed Name:
Date:
CT SPACE GRANT COLLEGE CONSORTIUM
203 Dana Hall, University of Hartford (Lead Institution)
200 Bloomfield Avenue, West Hartford, CT 06117
860-768-4813 [email protected] www.ctspacegrant.org
Central Connecticut State University
Medical Release Form
Participant’s Name _________________________________________ Date of Birth ______________
Physician’s Name ________________________________Physician’s Number ___________________
In participant currently taking any medications? ☐ YES ☐ NO If yes, please list medications and
explain.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Does the participant have any allergies or pre-existing medical conditions of which CCSU should be
aware? Please explain in detail any situation you, or your son or daughter, should be aware regarding
his/her condition?
_____________________________________________________________________________________
_____________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name
Cell Phone
Relationship to Participant
Home Phone
Work Phone
Address
City/State/Zip
Does the participant currently have medical insurance?
YES
NO
If yes, Name of Provider _______________________________ Policy # _________________________
Signature of Participant _________________________________ Date ________________________
If Participant is Under 21 Years Old:
In the event of a medical emergency, I authorize CCSU to advocate on behalf of my son/daughter. CCSU
is not responsible for any medical expenses incurred.
Signature of Parent/Guardian ________________________________ Date____________________
CT SPACE GRANT COLLEGE CONSORTIUM
203 Dana Hall, University of Hartford (Lead Institution)
200 Bloomfield Avenue, West Hartford, CT 06117
860-768-4813 [email protected] www.ctspacegrant.org