ADAPTED PHYSICAL EDUCATION TEACHING MINOR

APPLICATION FORM

(type all information)

STUDENT INFORMATION

Gender

 Female
 Male

Racial/Ethnic Heritage

(check one)
 African American/Black
 American Indian or Alaskan Native
Tribal Affiliation
 Asian American or Pacific Islander
(check one box)
 Cambodian, Hmong, Laotian, Vietnamese
 Other Asian Pacific Islander
 Hispanic/Latino
 White/Non-Hispanic

Are you a U.S. veteran?

 Yes No

Do you have a disability?

 Yes No
If yes, type of disability / Year and Semester you plan to enter: (check one)  Fall of  Spring of / Today’s Date:
Last Name First Middle
Student ID Number
Major(s):
Minor(s): / Year in School
 Freshman
 Sophomore
 Junior
 Senior
UWL Email Address / Permanent Phone / Credits completed
Secondary Email Address / Home Phone (if different from above) / Cumulative GPA
Permanent Home Address
Street
City
State Zip / Major GPA
Credits this semester
Anticipated Graduation
(check one)
 Fall
 Spring
 Summer
(year)
Local Address (if different from above)
Street
City
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/StatePhone
SIGNATURES
Completing the adapted physical education teachingminor 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:
Date Reviewed:
Application Complete Yes  No
Recommendation Yes  No / Credit  Yes  No
GPA  Yes  No
ESS 231  Yes  No
PETE Yes  No / Admission  Accepted
Admission Letter Sent:
Advisement Sheet Sent: / Admission  Denied
Reasons:
Denial Letter Sent: