APPLICATION
FOR ADMISSION
SELF SUFFICIENCY PROGRAM
424 C. Wimberly Hall,
1725 State Street,
University of Wisconsin-La Crosse
La Crosse, WI 54601 - 608-785-8733
NAME:________________________________________________
S.S.#_____________________
STREET ADDRESS:__________________________________________________________________
CITY, STATE, ZIP:___________________________________________________________________
PHONE: (H)________________________
(W)_________________________ SEX: F______
M_____
NUMBER OF CHILDREN:_______ NUMBER OF CHILDREN LIVING WITH YOU:_______
WILL YOU NEED CHILD CARE IN ORDER TO ATTEND CLASS?
YES_______ NO_______
(If so, please complete the following.
We do not determine your eligibility for the program by your need for
child care; however, we do need
this information to make the proper arrangements.)
NAME OF CHILD
AGE SPECIAL NEEDS/OTHER INFORMATION
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
EDUCATIONAL BACKGROUND
Do you have a high school diploma? YES___ NO___ If yes, when did you graduate?____
Do you have any additional formal education and/or training?
Please specify.
____________________________________________________________________________________
____________________________________________________________________________________
RECENT ACTIVITY
Please list the major activities in which you have engaged
during the last three years. (Include
such things as full-time parenting, employment, whether full or part-time...and
school).
ACTIVITY
PLACE (EMPLOYER, SCHOOL, CITY OF RESIDENCE) WHEN
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
REFERENCES
List three people who can speak knowledgeably about your
motivation and preparation for this kind of program.
NAME
PHONE NUMBER
RELATIONSHIP TO YOU
___________________________ ______________________
________________________________
___________________________ ______________________
________________________________
___________________________ ______________________ ________________________________
How did you hear about this program?___________________________________________ _________
___________________________________________________________________________________
Finally, please explain, in your own words, why you would like
to be a student in this program. Consider
both what difficulties you anticipate having to manage and what you have going
for you. Take the space you need,
but please, limit your answer to two pages.
____________________________________
YOUR SIGNATURE DATE