Stout Solutions � Continuing Education

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					            UW-Stout School of Education                                 University of Wisconsin-Stout • Reading Certification Application Form

Optional fields    *Student I.D. #                        Social Security Number:                                          Demographics:
are marked                                                                                                                 *Birth date
with an *.                                                                                                                 (mo/day/yr):
Please write                                                                                                               *US Veteran (yes or no):
n/a if not         Home E-mail address:
applicable.        Work/School E-mail address:                                                                             *Marital Status:                  *Sex:
                                                                                                                           (single/married)                  (M or F)

                                                                                                                           *Ethnic Background (check one):
Last Name, First Name, Middle                     Maiden (prior)          Work Phone               Cell Phone                 American Indian
                                                                                                                              Asian/Pacific Islander
Home Address: Street and #                 City & County              State/Zip                    Home Phone                     Cambodian, Laotian, or Vietnamese admitted to US
                                                                                                                                  after 12/31/75

Resident History                                                                                                                  Other Asian/Pacific Islander

Wisconsin Resident? (Y or N)                      If yes, From (mo/yr):                     To (mo/yr)                         Black, non-Hispanic
Teaching History                                                                                                               Hispanic/Latino
Teaching License? (Y or N)                   Level/Area:                                          State:                       White, non-Hispanic
                                             Level (ex. Early childhood, Elementary, or Secondary); Area (ex.
                                             Science or Reading focus, if applicable)                                      Citizenship(check one):
List Teaching Experiences and Activities                                                                                      Citizen
Occupation, activity, employer or school, including level and area.                                                           Non-resident Alien
                                                                               From:                 To:                      Permanent Immigrant
                                                                               From:                 To:                   Alien Reg #:
                                                                               From:                 To:                   Country of citizenship:

Signature Required                                                                                                         Place of Birth:
I certify that the information in the application is true and complete to the best of my knowledge and I understand
that inaccurate information may affect my enrollment or financial aid status. If I enroll at this university, I expect
to be subject to its rules and regulations.                                                                                (city, state, country)
      By checking this box you have created an electronic signature as legally binding as your
      handwritten signature
Outreach Services • Continuing Education                                 Education History
Submit             Email application attachment to:                      List graduating high school and any institutions, colleges or universities attended:
completed          Amy Gullixson                                                                                                                             Degree/diploma;
application to: If you have any                                  Name               Location         Dates                         date awarded
                   difficulty emailing the application as an             High School:
                   attached file, call Amy at 715-232-2253.              College(s):

                   Mail the transcript to: Amy Gullixson, 421            Have you taken courses offered
                   McCalmont Hall, UW-Stout, Menomonie,                  through UW-Stout on or off campus                 Do you plan to continue at UW-Stout
                   WI 54751                                              (yes or no)?                                      (yes or no)?
                                                                         If yes, are you a current student?                Intended major/program:
                                           Philosophy of Education/Statement of Goals

            Last                                        First                         Middle           Social Security Number

I am applying for admission into the reading teacher certification course sequence.

Directions for Formatting: Provide your response to the following areas by using double spacing with proper grammar, usage and spelling in approximately
500 words (not to exceed 3 double spaced computer generated pages).
Philosophy of Education/Statement of Goals
Your philosophy of education should provide examples of your commitment to learning, your commitment to excellence, and your respect for others. Include
indications of your efforts to create a learning environment in which all students can learn. Reference other accomplishments that make you a particularly
good candidate for admission to the UW-Stout Reading Certification program.

The professional goals you hope to achieve as a result of completing the reading certification program are to be cited. Your goals statement is a very important
part of your application.

***Save a copy of this document to include in the eportfolio you will develop during the reading certification program.

Note: A transcript is also required.
Mail the transcript to:
Amy Gullixson, 421 McCalmont Hall, UW-Stout, Menomonie, WI 54751

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