Application

Application for Admission

To submit electronically fill out the form below and click the "Submit" button
For a printable version please follow this link
To receive application by mail contact Amy Sullivan, Director, at (608) 785-8733 or sullivan.amy@uwlax.edu

As soon as we receive your Application we will send you information package by mail to the address you provided
If you may have any question please call Amy at (608) 785-8733

Name ...............

S.S# .................

Street Address ..

City, State, Zip ...

Phone: home# .... or work #

E-mail address....

Sex .................... F M

Number of Children ........................

Number of children living with you ...

Will you need Child Care in order to attend class ......Yes * No

* 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. If you will need Child Care, please complete the following:

Name and age of a child:

1.
2.
3.

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:

Activity Place (Employer, School, City of residence) When*

*(Include such things as full-time parenting, employment whether full or part-time and school).

References:

List three people who can speak knowledgeably about your motivation and preparation for this kind of program.

Name Phone # Relationship to you

1.
2.
3.

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 one typed page.

	The Self-Sufficiency Program

The Self-Sufficiency Program

Application for Admission