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Delta Application

What Delta Program are you applying to?

Internship
Certificate
Both Internship and Certificate

Applicant Contact Information

Name Email
Dept Degree Sought
 
Expected date of degree
 completion







Home Address
Home Phone
   
Campus Address
Campus Phone









Degree Research Advisor(s)

Name Email
Dept    




Campus Address
Campus Phone




(If more than one degree advisor, add below)

Name Email
Dept    




Campus Address
Campus Phone






Internship Faculty / Instructional Staff Partner(s)

Name Email
Dept    




Campus Address
Campus Phone




(If more than one internship partner, add below)

Name Email
Dept    




Campus Address
Campus Phone





Proposed Certificate Mentor

Would you like Delta to provide you with a certificate mentor?

Name Email
Dept    




Campus Address
Campus Phone






Delta Courses Completed
Please check all that apply. Note that there is a one (1) course prerequisite for the Delta internship, and two (2) courses are required for completion of the Delta Certificate.


Courses

Term Completed ex: Fall 2007
The College Classroom (EPD 654; Inter L&S; or Inter CALS 875)
The College Classroom - Summer Semester (EPD 654)

The College Classroom - Online (EPD 690; Inter L&S 701; Inter CALS 875)

Instructional Materials Development
(EPD 690; Inter L&S 701; Inter CALS 875; Botany 575)

Instructional Materials Development (Statistics Course)

Biology 375 -Engage Children in Science

Teaching in Science/Engineering: Int'l Students/Faculty (EPD 690)

Informal Education (Journalism 880; EPD 690; Inter L&S 701; Inter CALS 875)
Diversity in the College Classroom (EPD 690; Plant Path 801)

Effective Uses of Educational Technology
(EPD 690; Inter L&S 701; Inter CALS 875)

Delta Internship Seminar (ELPA 502)
CIRTL Network Course (please specify)

Other Course (Non-Delta courses require program approval) (please specify)











































Delta Programs Completed
Please check all that apply. Note that one (1) program is required for completion of the Delta Certificate.

 
Programs
Term Completed ex: Fall 2007
Expeditions in Learning (One semester program)
Creating a Collaborative Learning Environment (Full year program)
Research Mentor Training (One semester program)
Delta Central member* (One semester)
Steering Committee member* (Full year)
CIRTL Network liason* (One semester)
RoundTable Table Facilitator (4-6 events)
Other (Non-Delta programs require approval)














 

 

 

 

 

Required Additional Documents

 
Internship
Certificate
Curriculum Vitae (CV)
YES
YES
Project Proposal and Timeline
Proposed internship project and timeline for implementation
Proposed pathway and timeline through Delta activities
Letter of Intent form with Signatures
Form signed by degree research advisor and intern
Form signed by certificate applicant only

Please email the above files (pdf or doc format) to internship@delta.wisc.edu


You will receive a copy of this application in an email confirmation upon your submittal.

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