Project Success Application

Personal Information

Name*

First Last

Date*

mm/dd/yyyy

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

(###) ###-####

Email*

Date of Birth*

mm/dd/yyyy

Age*

Parents Names

Father*

First Last

Mother*

First Last

Parent Phone Number*

(###) ###-###

Parent Email*

Residency Status

Are you a Wisconsin or Minnesota resident for tuition purposes?*

Yes, I am a Wisconsin or Minnesota resident and plan to pay resident tuition
No, I am a non-resident and plan to pay non-resident tuition

What is your expected High School Graduation date?*

mm/dd/yyyy

Information About Your Disability

Date of initial evaluation of dyslexia or learning disability*

mm/dd/yyyy

Please send a copy of your most recent documentation with this application

Please provide the following information on the person who first or most recently diagnosed your learning disability or dyslexia:

Name*

First Last

Professional Title*

What is the date of your most recent evaluation of your disability?*

mm/dd/yyyy

Do you have a copy of your most recent evaluation?*

Yes
No

Please check the areas that are most difficult for you because of your disability:

Reading*

Word Attack
Reading Rate
Comprehension

Written Expression/ Spelling*

Spelling
Writing Mechanics
Paragraph/ Theme Development

Mathematics*

Basic Facts
Story Problems
Basic Operations/ Calculations

Study Skills*

Note-taking
Test Preparation
Time Management

High School Information

Please provide the name and address of the high school where you graduated or are currently attending:

School Name*

School Location*

Did you receive Special Education Services during High School?*

Yes
No

Did you have an Individualized Education Plan?*

Yes
No

What types of services did you receive?*

Extra Testing Time
Test Reader
Resource Room

Postsecondary Education Information

Have you attended a postsecondary school such as a college, university or technical school?*

Yes
No

School Name

School Location

Start Date

mm/dd/yyyy

End Date

mm/dd/yyyy

Credits Earned

GPA

0.00

Did you receive accommodations for your disability at this institution?

Yes
No

What types of services did you receive?

Extra Testing Time
Test Reader
Resource Room

How did you hear about Project Success?*

Did you see a representative of Project Success at a Transition fair and/or campus visit?*

Yes
No

If so, which state/fair and/or Project Success representative?

Application To-Do List

Please make sure to include the follow when submitting the application:

Copy of Most Recent Disability Documentation*

ACT Scores*

High School Transcript complete through Junior Year*

Senior Year Schedule*

Hand-written Letter of Interest*

Date sent in*

mm/dd/yyyy

Project Success Application

Personal Information

Parents Names

Residency Status

Information About Your Disability

**Please send a copy of your most recent documentation with this application**

High School Information

Postsecondary Education Information

Application To-Do List

Project Success recommends applying to the program during second semester Junior year or first semester Senior year.

Please send a copy of your most recent documentation with this application