Scholarship Application Form

Scholarship Application Form
Fall Collaborative Group

Mail this form and attachments to:
Distance Education Certificate Program
University of Wisconsin-Madison
225 N. Mills St., 110 Teacher Education Bldg.
Madison, WI 53706-1707
Or fax to: (608) 265-7848
Downloadable ASCII text format for word processing.

Name: ________________________________________________________
Title: _______________________________________________________
Organization: ________________________________________________
Address: _____________________________________________________
___________________________________________________________
______________________________________________________________
Phone: ______________________________________________________
Fax: ________________________________________________________
E-mail: _____________________________________________________
1. What model computer do you have? _____________________________
2. Do you currently have Internet/Web access? ___ Yes ___ No
3. How fast is your Internet connection? ___ High-speed broadband or DSL ___56 kbps modem ___Don't know
4. How much time per week can you commit to Certificate Program work, and when will you schedule this time (e.g., during work hours, weekends, evenings):

5. What previous experiences do you have, if any, in online collaborative (group) learning?

6. Why do you think group-based collaborative learning may benefit you?

7. Please explain why you need scholarship funding.

8. What prior experience do you have, if any, in distance education?

Attach:

1. A one to two page letter of application describing

A. Your current job responsibilities,
B. Your reasons for wanting to enroll in the Certificate Program,
C. Your reasons for applying for this scholarship.

2. Your resume or vita.
3. The names, addresses, and phone numbers of two references.

Scholarship Application Form Fall Collaborative Group
Mail this form and attachments to: Distance Education Certificate Program University of Wisconsin-Madison 225 N. Mills St., 110 Teacher Education Bldg. Madison, WI 53706-1707 Or fax to: (608) 265-7848 Downloadable ASCII text format for word processing. Name: ________________________________________________________ Title: _______________________________________________________ Organization: ________________________________________________ Address: _____________________________________________________ ___________________________________________________________ ______________________________________________________________ Phone: ______________________________________________________ Fax: ________________________________________________________ E-mail: _____________________________________________________ 1. What model computer do you have? _____________________________ 2. Do you currently have Internet/Web access? ___ Yes ___ No 3. How fast is your Internet connection? ___ High-speed broadband or DSL ___56 kbps modem ___Don't know 4. How much time per week can you commit to Certificate Program work, and when will you schedule this time (e.g., during work hours, weekends, evenings): 5. What previous experiences do you have, if any, in online collaborative (group) learning? 6. Why do you think group-based collaborative learning may benefit you? 7. Please explain why you need scholarship funding. 8. What prior experience do you have, if any, in distance education? Attach: 1. A one to two page letter of application describing A. Your current job responsibilities, B. Your reasons for wanting to enroll in the Certificate Program, C. Your reasons for applying for this scholarship. 2. Your resume or vita. 3. The names, addresses, and phone numbers of two references.