UW-La Crosse, 4306 Centennial Hall
1725 State Street
La Crosse WI 54601
608.785.8733
Application for Admission
Contact Information
Name_______________________________________________________
M \ F (circle)
Mailing Address____________________________________________________________
City, State, Zip______________________________________________
Phones (Home)____________________(Work)__________________(Cell)___________________
Birth date__________________ Email address___________________________________
Best days/times to reach you_________________________________________________
Best way to reach you(phone, email)
________________________________________
Educational Background
Do you have a high school diploma? Yes No
GED/HSED? Yes
No
If yes, what year did you graduate or get your GED/HSED?_____________
Please list all additional formal education or special training you have received:
Children
Please list the Name(s) and Age(s) of your children below:
Will you need childcare in order to attend the class? Yes
No
If Yes, how many of your children will need childcare?__________
Please inform us of any special needs or information we might need to know about your
children for childcare purposes:
Recent Work/Life Activities
Please list the major activities in your life during the past several years. Include work,
parenting, school, church and volunteer activities.
Activity
Place/Organization/Location
Year/Time frame
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________
References
Please list three people who can speak knowledgeably about your motivation and
preparation and interest in this kind of program.
Name
1)
2)
3)
How did you hear about SSP?
Daytime Phone
Relationship to you
Please list below any other circumstances that the admissions committee should be
aware of regarding your interests, your past, your motivations or other concerns.
Essay
Finally, in your own words, please explain why you would like to be a student in this
program. Please include below a brief statement about your interest in this program, the
challenges you may face trying to attend the course and/or accomplish your long-term
goals, and share with us skills and other assets you will bring to our classroom. This is
the most important part of your application, so please answer this part completely.
_____________________________________
Your signature
date
Send your completed application to the address listed on pg. 1 of this application.