Special Physical Education Concentration

ADAPTED PHYSICAL EDUCATION TEACHING MINOR APPLICATION FORM (type all information)

STUDENT INFORMATION Gender  Female Year and Semester you plan to enter: (check one)  Fall of  Spring of Today’s Date:  Male Last Name First Middle Racial/Ethnic Heritage (check one) Student ID Number  African American/Black  American Indian or Year in School Alaskan Native Major(s):  Freshman

 Sophomore Tribal Affiliation  Junior  Asian American or Minor(s): Pacific Islander  Senior (check one box)  Cambodian, Hmong, UWL Email Address Permanent Phone Credits completed Laotian, Vietnamese  Other Asian Pacific Islander Secondary Email Address Home Phone (if different from above) Cumulative GPA  Hispanic/Latino  White/Non-Hispanic Permanent Home Address Major GPA Are you a U.S. veteran? Street  Yes  No Credits this semester City Do you have a disability?  Yes  No State Zip Anticipated Graduation (check one) If yes, type of disability Local Address (if different from above)  Fall  Spring Street  Summer

City (year) State Zip

ESS 231: Semester/Year Taken

Have you been formally admitted to the Physical Education Teacher Education program?  Yes  No If yes, semester/year admitted

List and describe any experiences you have had working with individuals who are disabled. (Attach additional page if necessary) State why you would like to complete the Adapted Physical Education Teaching minor. Further, state how this teaching license will fit into your career goals. (Attach additional page if necessary)

REFERENCES (identify 2 references who are familiar with your teaching ability– you may include the individual who is submitting a reference form on your behalf)

Name and Title City/State Phone

SIGNATURES

Completing the adapted physical education teaching minor will take a minimum of 3-4 semesters to complete. Admission preference will be given to applicants who are the most qualified. Meeting minimal qualifications does not guarantee admission into the minor.

I have read and understand the statements above. (Applicant’s signature)

I certify that the information in this application is true and compete to the best of my knowledge. I understand that inaccurate information may affect my admission status. If I enroll in this minor, I will abide by its rules and regulations.

(Applicant’s Signature) (Date)

Office Use Only

Date Received: Admission  Accepted Admission  Denied Date Reviewed: Credit  Yes  No GPA  Yes  No Admission Letter Sent: Reasons: Application Complete  Yes  No ESS 231  Yes  No Recommendation  Yes  No PETE  Yes  No Advisement Sheet Sent: Denial Letter Sent: