2017 Application In alignment with the UW-Madison’s 2014 Diversity Framework, the Information Technology Academy (ITA) is an innovative pre-college initiative for diverse students in the state of Wisconsin. With programs serving Wisconsin’s Madison (grades 9-12), Lac du Flambeau (grades 10-12), and Oneida (grades 10-12) communities, ITA’s goal is to increase the enrollment rates of diverse students at the University of Wisconsin-Madison. ITA’s Lac du Flambeau and Oneida programs form the Tribal Technology Institute (TTI). ITA is offered at no cost to the participants, and all participants receive a computer loan.

All selected students receive intensive training for technology-related careers, as well as preparation for competitive university admissions. Students build knowledge and skills through hands-on coursework, mentoring, leadership development, community service, academic seminars, outreach events, portfolio development, and internship opportunities. ITA is the only comprehensive information technology outreach program in the state of Wisconsin. All students are encouraged to apply. Please note that participation in ITA replaces participation in the high school PEOPLE program; students are not allowed to participate in both programs at the same time. For more information, visit http://ita.wisc.edu.

Application Instructions: For your application to be complete, you must include the following required materials, with complete, printed or typed information:

1. This application form (page 2-6).

2. A personal statement.

3. A letter of recommendation from a parent or guardian.

4. A letter of recommendation from a teacher or school counselor.

5. A teacher or school counselor evaluation submitted by the SAME teacher or school counselor who wrote your letter.

6. Student report cards that include your cumulative GPA, class grades, and attendance record for each year:

• ITA-TTI Lac du Flambeau Applicants should submit their middle school grades (6th, 7th, and 8th grade final report cards) and their first semester freshmen year grades (9th grade first semester report cards).

• ITA Madison Applicants should submit their middle school grades (final 6th, final 7th, and first semester through Quarter 3 8th grade report cards).

• ITA-TTI Oneida Applicants should submit their middle school grades (6th, 7th, and 8th grade final report cards) and their first semester freshmen year grades (9th grade first semester report cards).

How to Submit Your Application: ITA cannot accept applications in person or by email. ITA Madison students should submit applications to their school counselors or by fax to (608) 265-3145. ITA-TTI students can submit their application to their school counselor, YES coordinator, their local ITA staff, or by fax (608) 265-3145. School counselors who submit applications on behalf of their students should contact Ron Jetty for access to an online submission folder.

ITA/ITA Madison ITA-TTI Lac du Flambeau ITA-TTI Oneida Ron Jetty Julie Hagstrom Lauren Mauel Executive Director Student Success Student Success ron.jetty@wisc.edu Outreach Coordinator Outreach Coordinator Phone. (608) 265-3145 julie.hagstrom@wisc.edu lauren.mauel@wisc.edu Fax. (608) 265-6453 Phone. (715) 892-2100 Phone. (608) 416-7708

Applications must be received by 5:00 p.m. on March 10, 2017.

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STUDENT INFORMATION

First Name

Middle Initial

Last Name

Date of Birth _ _ / _ _ / _ _ _ _

Gender � Female � I identify as _________________. � Male � Prefer not to say

Street Address Street: ________________________________ City, State: ____________________________ Zip Code: _____________________________

Mailing Address (If different from street address) Street: ________________________________ City, State: ____________________________ Zip Code: _____________________________

Student Phone(s)

Student Email(s)

You must be a U.S. citizen or permanent resident to enroll in ITA. Please check one to indicate your status with respect to U.S. citizenship or permanent residency.

� I am a citizen.

� I am a permanent resident.

� Other:

Are you eligible for Free or Reduced Price School Meals?

� Yes � No

Are you of Hispanic, Latino or Spanish origin? Please check all that apply.

� No, not of Hispanic, Latino, or Spanish origin. If you wish, please specify other ethnic heritage with which you identify: ____________________________________ � Yes, Mexican, Mexican American, or Chicano � Yes, Puerto Rican � Yes, Cuban � Yes, other Hispanic, Latino, or Spanish origin. Print origin (e.g. Guatemalan, Salvadoran, etc.):

___________________________________________

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With which race(s) do you identify? Please check all that apply.

� African American or Black � American Indian or Alaska Native. Please specify name of enrolled or principal tribe: _________________________________________ � Cambodian � Hmong � Laotian � Native Hawaiian/Pacific Islander � Vietnamese � White � Other Asian (Thai, Pakistani, Chinese, etc.). Please specify____________________________________ � Other Race, Multi-racial, Bi-racial. Please specify: _________________________________________

Do you have a parent/guardian who completed a four-year college degree?

� Yes � No

Regarding your access to technology, which of the following do you have? Please check all that apply.

� A computer in my home that I share with other family members. � A high-speed internet connection (cable modem, DSL, etc.). � My own email address. � My own web page. � My own computer. � A dial-up internet connection. � My own cell phone. � Other __________________

What is your anticipated year of graduation from high school? Graduation year should be 2021 for ITA Madison applications, 2020 for ITA-TTI Oneida and ITA-TTI Lac du Flambeau.

� 2020 � 2021

What school do you presently attend? What high school will you be attending in the fall? What is the name of your school district? Are you in the middle school PEOPLE Program? � Yes

� No Do you currently have a mentor, either informally or formally assigned through another program? � Yes

How did you hear about ITA? Please check all that apply.

� Presentation at my school by ITA staff � School counselor � Teacher � ITA Website � Friend/family member � PEOPLE Program presentation � Tribal liaison or community member � Other: _________________________

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Every ITA student receives a tee-shirt. Please indicate your tee-shirt your size.

� S � XL � M � XXL � L � Other size: ____________

PARENT / GUARDIAN INFORMATION

FIRST PARENT / GUARDIAN

Parent/Guardian Name

Relationship to Student

Street Address

City, State, Zip Zip: Home Phone ( _ _ _ ) _ _ _ - _ _ _ _

Cell Phone ( _ _ _ ) _ _ _ - _ _ _ _

Work Phone ( _ _ _ ) _ _ _ - _ _ _ _

Email Address

Occupation

Employer

SECOND PARENT / GUARDIAN

Parent/Guardian Name

Relationship to Student

Street Address

City, State, Zip

Home Phone ( _ _ _ ) _ _ _ - _ _ _ _

Cell Phone ( _ _ _ ) _ _ _ - _ _ _ _

Work Phone ( _ _ _ ) _ _ _ - _ _ _ _

Email Address

Occupation

Employer

EMERGENCY CONTACT INFORMATION (Your emergency contact cannot be your parent/guardian.)

Name

Relationship to Student

Primary Phone ( _ _ _ ) _ _ _ - _ _ _ _

Secondary Phone ( _ _ _ ) _ _ _ - _ _ _ _

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STUDENT PERSONAL STATEMENT

In 300 words or fewer, please share with us (1) your academic interests, technology passion, and career goals; (2) what you would like to learn from the Information Technology Academy; and (3) how you think the Information Technology Academy would benefit from having you as a participant.

PARENT/GUARDIAN LETTER

Please include a letter of recommendation from a parent or guardian. The letter should demonstrate understanding of the ITA program and should include reasons why the parent(s)/guardian(s) would like your child to participate as well as a list of ways you will support their participation. This letter should be more than just granting your child permission to participate. Parents/guardians may write their letter in any language. If the letter is dictated to someone else, please include his/her name and contact information.

TEACHER OR SCHOOL COUNSELOR EVALUATION

A teacher or school counselor who knows the student well should submit the ITA Teacher or School Counselor Evaluation form in a confidential manner. Please use the form to evaluate the student in relation to his/her peers based on your professional experience. It can be faxed to ITA at (608) 265-6453 or given to the student in a sealed envelope, and the student can submit it with the rest of his or her application materials. This form can be downloaded from our website at http://ita.wisc.edu/apply.php.

TEACHER OR SCHOOL COUNSELOR LETTER OF RECOMMENDATION

With the teacher or school counselor evaluation, please include a letter of recommendation. The letter of recommendation should be from the same teacher or school counselor who completed the evaluation. This confidential letter should discuss the student's goals, level of motivation, attitude, and academic support needs. Additionally, please elaborate in the letter if a student is particularly weak or strong in any of the areas listed above. Thank you for taking the time to complete this evaluation. Your reflections are an important part of this student's application to the Information Technology Academy. Your input will be kept confidential and will not be shared with the student or family.

GRADE REPORTS

ITA-TTI Oneida applicants should submit their middle school grades (final 6th, 7th, and 8th report cards) and freshman grades (first semester 9th grade report card). Please include cumulative GPA, class grades, and attendance record for each year.

ITA Madison applicants should submit their middle school grades (final 6th, final 7th, and first semester through Quarter 3 8th grade report cards). Please include cumulative GPA, class grades, and attendance record for each year.

ITA-TTI Lac du Flambeau applicants should submit their middle school grades (final 6th, 7th, and 8th report cards) and freshman grades (first semester 9th grade report card). Please include cumulative GPA, class grades, and attendance record for each year.

SUPPLEMENTAL APPLICANT INFORMATION

Please upload or include additional materials you would like the admissions committee to consider with your application (PDF, Word, video, link). Additional materials are not required, but rather optional.

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APPLICANT CHECKLIST

This application form (pages 2-6).

A personal statement.

A letter of recommendation from a parent or guardian.

A letter of recommendation from a teacher or school counselor.

A teacher or school counselor evaluation submitted by the SAME teacher or school counselor who wrote your letter.

Student report cards that include your cumulative GPA, class grades, and attendance record for each year:

• ITA-TTI Lac du Flambeau Applicants should submit their middle school grades (6th, 7th, and 8th grade final report cards) and their first semester freshmen year grades (9th grade first semester report cards).

• ITA Madison Applicants should submit their middle school grades (final 6th, final 7th, and first semester through Quarter 3 8th grade report cards).

• ITA-TTI Oneida Applicants should submit their middle school grades (6th, 7th, and 8th grade final report cards) and their first semester freshmen year grades (9th grade first semester report cards).

APPLICANT AGREEMENT

I read the Information Technology Academy (ITA) Applicant Information (available online at http://ita.wisc.edu/apply) and understand the program requirements. I am ready to make the commitment and continue down the path to success. I certify that the information provided in my application is true and acknowledge that falsification may result in dismissal from the program and/or loss of scholarship eligibility. I am willing to abide by the conditions and regulations of the University of Wisconsin-Madison and the ITA if I am selected to participate.

Signature of Student Date

PARENT/GUARDIAN APPROVAL

I agree to the release of my child's middle school and high school records, test scores, and verification of qualification for free and/or reduced lunch by his/her school district to the University of Wisconsin-Madison Information Technology Academy. If my child is selected, I agree to support his/her participation in the Information Technology Academy fully for the duration of the program. I certify that the information provided is true and acknowledge that falsification may result in dismissal from the program and/or loss of scholarship eligibility.

Signature of Parent Date

Applications must be received by 5:00 p.m. on March 10, 2017.

2017 Teacher or School Counselor Recommendation and Evaluation

The Information Technology Academy (ITA) requires each student applying to the program to have a teacher or school counselor submit this evaluation and a recommendation letter on the student’s behalf by 5:00 p.m. on March 10, 2017. The same teacher or counselor must complete both the evaluation form and the recommendation letter. The documents will not be shared with the student or family. Your insight into your student’s academic potential and technology interest can make the difference in whether your student gains acceptance to ITA. Thank you for supporting students who seek to participate in ITA.

TEACHER OR SCHOOL COUNSELOR LETTER OF RECOMMENDATION A teacher or school counselor who knows the student well should submit a letter of recommendation in support of the student applying to ITA. This confidential letter should discuss the student's goals, level of motivation, attitude, and academic support needs. Additionally, please elaborate in the letter if a student is particularly weak or strong in any of the areas listed above. In your recommendation letter, please include the following:

• Your name • Your professional title • Your school name • Your email address

• Your phone number • The name of student applying to ITA • Your relationship to the student

If a student asked you to complete a recommendation, please be sure to submit this evaluation form with your recommendation letter.

TEACHER OR SCHOOL COUNSELOR EVALUATION A teacher or school counselor who knows the student well should submit the evaluation below in support of the student applying to ITA. In a confidential manner, please evaluate the student in relation to his/her peers based on your professional experience and the criteria provided below. If a student asked you to complete an evaluation, please be sure to submit a recommendation letter with this evaluation.

HOW TO SUBMIT YOUR RECOMMENDATION LETTER AND EVALUATION ITA cannot accept applications in person or by email. ITA Madison students should submit applications to their school counselors or by fax to (608) 265-3145. ITA-TTI students can submit their application to their school counselor, YES coordinator, their local ITA staff, or by fax to (608) 265-3145. School counselors who submit applications on behalf of their students should contact Ron Jetty for access to an online submission folder: Ron Jetty Julie Hagstrom Lauren Mauel ITA, Executive Director Lac du Flambeau Student Success Oneida Student Success ron.jetty@wisc.edu Outreach Coordinator Outreach Coordinator Phone. (608) 265-3145 julie.hagstrom@wisc.edu lauren.mauel@wisc.edu Fax. (608) 265-6453 Phone. (715) 892-2100 Phone. (608) 416-7708

2017 Teacher/Counselor

Recommendation and Evaluation

Thank you for your invaluable insight and support to students applying to ITA. See http://ita.wisc.edu or call (608) 265-3145 for more information.

EVALUATION

Teacher / School Counselor Information

Teacher / School Counselor Name

Title and Relationship to Student

School Name

Name of Student Applying to ITA

Email Address Phone

Please evaluate the student applying to the Information Technology Academy (ITA) in relation to his/her peers based on your professional experiences according to these criteria:

• Exceptional = Top 10% of all students I have ever taught. • Excellent = Top 10% of students in his/her grade. • Above Average = In the 10-20th percentile of students in his/her grade. • Average = In the 20-50th percentile of students in his/her grade. • Below Average = Below the 50th percentile of students in his/her grade.

Exceptional Excellent Above

Average Average Below

Average No Basis for Judgment

Academic potential

Intellectual curiosity Ability to follow through to complete a task/project

Ability to work independently

Ability to work in a group

Respectfulness toward adults

Respectfulness toward peers

Acceptance of feedback

Organization

Participates Constructively

Responsibility

Overall evaluation of student

Please sign below to certify that, to the best of your knowledge, the information you provided about the student is true and complete. ________________________________________________________________________________ Teacher or Counselor Signature Date