Delta Program: Internship and Certificate Application

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The Delta Program is supported by the
University of
Wisconsin-Madison

The Delta Program and
UW-Madison are partners
in the CIRTL Network

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

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) (please specify)

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

Attach documents here

Curriculum Vitae (CV)
Internship Project Proposal
Internship Letter of Intent / Signatures
Certificate Proposed Pathway / Timeline
Certificate Letter of Intent/ Signatures

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