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CSA Class Grant Program

CSA Class Grant Program
to support Learning (STUDENTS)

APPLICATION FORM

Canadian Space Agency
Space Learning Program
6767 Route de l'Aéroport
Saint-Hubert, Québec
J3Y 8Y9 Canada

Instructions for completing this form:

You must answer all fields as indicated. Your application will not be considered if there is missing or incomplete information.

Submit this application form with all other necessary documentation (proof of student status & citizenship; letter of reference).

For any additional information, please contact Jason Clement.

It is the applicant's responsibility to ensure that the application complies with all relevant federal, provincial/territorial and municipal laws.

Given Name of Applicant:

Family Name of Applicant:

Address:

City:

Province:

Postal code: (ex : J3Y8Y9)

Telephone Number: (ex : 450-123-4567)

E-mail address:

Confirm E-mail address:

Applicant Academic Status:

I will be a student enrolled at a recognized academic institution at the time of the learning opportunity

Applicant Citizenship Status:

Applicant Academic Affiliation:

School Name:

Initiative to which I am applying:

If other, type of initiative to which funding is being requested:

(please specify)

Training Activity

Indicate the highest level of schooling completed:

Indicate your current level of study:

I understand that I will be contacted to participate in pre-funding, post-funding, and follow-up (if applicable) evaluation surveys, regardless of the outcome of my application for funding.

Please describe any work, research, community or other experience in space-related discipline(s):

Please indicate any interest and career goals in space discipline(s):

Description of Learning Opportunity:

Please provide a short description of the learning opportunity to which you are applying for funding, including date, title and location.

Purpose of attending the Learning Opportunity:

Please provide a short description of what specific learning objectives you hope to attain in participating in the initiative and how it relates to your academic or professional aspirations (e.g. Through my participation in this workshop I will learn more about how protein crystals react in a weightless environment and use this knowledge in the development of my Master's thesis).

Sharing of knowledge:

Please provide at least two concrete examples of how other Canadian students will benefit from the knowledge gained through your participation in the learning opportunity.

Project financial support:

Outline any current and proposed future funding from other sources to support the proposed activity.

Source (Name of institution and funding program)

Amount

Pending /
Granted? ¹

For pending funds, date for announcement

Attach notification letter

¹ Attach a copy of the notification letter. This should clearly identify the project name, funding agency and the result(s) of the demand. For awards that are pending, please indicate the expected date for the announcement.

Proposed cost associated with participating in learning opportunity:

Registration costs:

If travel is required to participate, please indicate which mode(s) will be used:

If accommodation is required, please indicate the number of nights as well as the number of people per room:

Please indicate if any meals are included in registration or accommodation costs:

Please indicate any additional costs required that fall into one of the eligible categories listed below:

Eligible costs are direct expenses associated with the participation in the approved learning activity. Expenses, which include one or a combination of items listed below, will be reimbursed subject to the applicant signing a Funding Agreement, in the form of a grant agreement, with the CSA.

Eligible Expenses

participation fees at conferences, committees and events;
travel;
accommodation and meals allowances;
training;
translation services;
tuition fees;
registration fees;
cost related to obtaining security clearance;
acquisition, development and printing of materials;
marketing and printing services;

Privacy Notice

Necessary measures have been taken to protect the confidentiality of the personal information you provide. The information you provide is collected under the authority of the CSA Act. This information will be used to determine the eligibility of applicants for subsidy funding and may be used to subsequently provide you with information on other available learning opportunities.

Your personal information will be held in the CSA Personal Information Bank for the appropriate program for 2 years. It is protected under the Privacy Act. According to the Privacy Act, you have rights with respect to the information you submit. You may upon request:

Be given access to your file
Have incorrect information corrected or have a notation attached

For more information about your rights see Info Source. This is a Government of Canada publication available in major libraries, at government information offices and from constituency offices of federal Members of Parliament.

Space Learning Grants Program Committee
Request Assessment Form (SAMPLE)

Requirement	1 Does not meet requirement	2 Does not meet requirement
Level of education and/or experience of applicant is appropriate for participation in event
Applicant demonstrates a clear interest in pursuing learning opportunities, studies and/or careers within space disciplines
The extent to which the proposed event meets Program objectives.
The quality of the event in terms of the depth of knowledge about Canadian space science and/or technology it offers students
Transferability of the knowledge acquired by participating in the event to other students, educators or institutions