Father/Guardian (circle one) Name Address City State ZIP Occupation

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1 Summer 2017 Application July 9 th -July 28 th, 2017 College Access Program (CAP) School of Education, UW-Madison 105 Education Building, 1000 Bascom Mall Madison, WI Phone: Fax: Student Last Name First Name M.I. Address City State ZIP Home Phone ( ) Cell Phone ( ) Date of Birth Gender: Male Female Transgender American Racial/Ethnic Heritage Please check the appropriate box Black/African American (non-hispanic) Asian American/Pacific Islander Vietnamese, Cambodian, Laotian or Hmong Pacific Islander Native Hawaiian Other Asian American American Indian or Alaskan Native Tribal Affiliation Hispanic/Latino Mexican, Mexican American, Chicana/o, Puerto Rican, or Cuban Other White (non-hispanic) Biracial/Multiracial High School Information High School Name High School City High School Counselor Anticipated Graduation Date Intended College Major Current Grade in High School 9th 10th School Transcript Attached: Yes No Student needs to submit a full school transcript. School Hot Lunch Program: Please check one, if applicable. Eligible for free hot lunch program. Yes No Eligible for reduced hot lunch program. Yes No First Generation College Student: Yes No A student is considered first generation college student if neither his/her Father/Guardian (circle one) Name Address City State ZIP Occupation Cell Phone ( ) Home Phone ( ) Work Phone ( ) Mother/Guardian (circle one) Name Address City State ZIP Occupation Cell Phone ( ) Home Phone ( ) Work Phone ( ) Contact person in case of emergency if parent/guardian cannot be reached: Name Relationship to Student Phone ( ) Applicant Agreement: I will abide by the conditions and regulations of the University of Wisconsin-Madison and the College Access Program if I am selected to participate. Date Signature of Student Parent s Approval: I do I do not grant permission for my child to be named, pictured or quoted in any news release and/or program promotional materials. _ Date Signature of Parent Page 1 of 4

2 Are you interested in attending UW-Madison? Yes No Please explain: Are you interested in joining the School of Education at UW-Madison? Yes No If yes, please select the major of your interest in the School of Education (select all that apply): Art Athletic Training Communication Disorder Dance Education Elementary Education Kinesiology Rehabilitation Psychology Theater & Drama Special Education To learn more about the majors, please visit:

3 Application Checklist Program Application: Please complete and submit the provided application form. Personal Statement: Please write a 300-word personal statement answering two of the four following questions: 1. Please discuss 3 personal goals you hope to reach by participating in CAP. For example, what experiences, knowledge, and skills do you hope to get out of the summer program? 2. What will you bring to the program/what sets you apart from other applicants? For example, how will your attitude, personality, and experiences positively impact the summer program? 3. Discuss your educational background, including academic strengths, weaknesses and any special needs. 4. Discuss your family background, including information like, but not limited to, the number of family members at home, their educational background, and their views about education. Letter of Recommendation: Please submit a sealed and signed letter of recommendation from a teacher, school counselor, work supervisor, or mentor (cannot be a family member or relative) that can speak to your strengths and ability to successfully complete the College Access Program. School Transcript Attached: Please submit a full high school transcript. Request for Financial Aid (Optional): The cost for CAP is $500 for the duration of the threeweek program. If you are unable to finance the total cost, you may apply for a CAP scholarship, please complete and submit the Request for Financial Aid application with your application packet. (Please note that you must include a statement of financial need with this form to be considered for a scholarship.) Summer 2017 Application A completed (1) program application, (2) 300-word statement, (3) letter of recommendation, and a (4) full high school transcript must be submitted by April 22nd, 2017 to receive full consideration. Mail to: College Access Program (CAP) School of Education, UW-Madison 105 Education Building 1000 Bascom Mall Madison, WI 53706

4 REQUEST FOR FINANCIAL AID Limited Number of Scholarships are Available INSTRUCTIONS: Scholarships are available to students who can demonstrate financial needs. Fill out Section I completely. Parent/Guardian must sign in the space provided. Give the form to your teacher, counselor, or principal for completion of Section III. Students who are disruptive or sent home from precollege programs may forfeit the opportunity for participation in future programs. SECTION II SCHOLARSHIP AMOUNT REQUEST SECTION I STUDENT INFORMATION Student Last Name Student First Name Student M.I. (Please note that limited funding is available, so please only request the amount that is needed.) Grade Level at Time of Program 9 10 Street Address City State Zip Telephone No. ( ) Race/Ethnicity Check all that apply (For Gender Date of Birth School Presently Attending Statistical Purposes Only) Male Mo./Day/Yr American Indian/Alaska Native Female Hispanic/Latino Trans* Scholarship Amount Requested Asian/Pacific Islander White Black/African American The fee for College Access Program is $500. This fee covers instruction, advising, room/board and supplies. Full and partial scholarships are available to students who can demonstrate financial need. To be considered for a scholarship you must submit a statement to explain extenuating circumstances that prevent your family from providing you with part or full financial support for the College Access Program (1-2 paragraphs). Please indicate if you are requesting a partial or a full scholarship. We will contact you with the results and the amount of the allocation, if applicable. You are responsible for the balance of program fees above the scholarship amount. Are you eligible for free or reduced school meals? Yes... No. I HEREBY AUTHORIZE release of my child s academic records to the University of Wisconsin-Madison. Signature of Parent/Guardian Date Signed! SECTION III REFERENCE Please provide contact information for a person of reference who can speak to your economic situation (ex. school teacher, counselor, family member, community organization member, church member, etc.) Full Name of Reference Address Telephone Area/No. ( ) Relationship to Applicant

5 WISCONSIN RESIDENTS MUST COMPLETE THIS FORM Page 4 of 5 Wisconsin Department of Public Instruction PRECOLLEGE SCHOLARSHIP APPLICATION PI-1573 (Rev ) You may receive a maximum of three DPI Precollege Scholarships per year. INSTRUCTIONS TO THE STUDENT AND PARENT/GUARDIAN: Student must be eligible for Free or Reduced Price School Meals and, must have finished Fifth Grade, but not have graduated from High School to receive a DPI Precollege Scholarship. Fill out Section I completely. Parent/Guardian must sign in the space provided. Give this form to your Principal, Food Services Authorized Representative or a DPI/WEOP Staff Member for completion of Section II. Students who are disruptive or sent home from a Precollege Program may forfeit the opportunity to participate in future programs. College Access Program School of Education, UW - Madison 105 Education Building 1000 Bascom Mall Madison, WI I. STUDENT INFORMATION Name Last First Middle Initial Street Address City State Zip Date of Birth Sex Male Female Ethnic Category Check only one (For Statistical Purposes) Hispanic or Latino Not Hispanic or Latino Racial Categories Check all that apply American Indian or Alaska Native Asian Black or African-American Native Hawaiian/Other Pacific Islander White Current Grade Level Anticipated Year of High School Graduation School Presently Attending School District Name I HEREBY AUTHORIZE release of my child s verification of Free or Reduced Price School Meals eligibility to the Precollege Campus and DPI. Signature of Parent/Guardian Ø Date Signed II. VERIFICATION AND RECOMMENDATION Instructions to the Principal, Food Services Authorized Representative, or DPI/WEOP Staff Member: Please verify that this student is eligible for Free or Reduced Price School Meals and forward this application form to the College or University where the student has applied for admission to a DPI Precollege Program. Is this student eligible for Free or Reduced Price School Meals? Yes No I have verified that this student is eligible for Free or Reduced Price School Meals and I recommend this student for a DPI Precollege Scholarship. Name of Authorized Representative Title Telephone Area/No. Verification Signature Ø Date Signed

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