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Leadership Certificate Record of Activities
Print Form School of Medicine and Public Health Leadership Certificate Application Name:____________________________________ ID# _________________ E-mail: ______________________________ (Please Print) Address: _______________________________ City: ______________________ State: ________ Zip Code: ____________ Please consider this application for the: _____ Spring semester deadline (materials due to the Student Organization Office by April 1). Leadership Certificate Application Checklist _____ _____ _____ _____ _____ Currently enrolled UW-Madison student with cumulative grade point of 3.0 or above and in good standing Completed “Leadership Certificate Activity Summary” and “Leadership Certificate Activity Record” Completed Educational Artifact Signed ethics statement at the end of this sheet Materials delivered by semester deadline to the Center for Leadership and Involvement, Room 239 Red Gym, 716 Langdon Street, Madison, WI 53706 Questions can be directed to the Center for Leadership and Involvement at 608-263-0365 or [email protected] Leadership Certificate Activity Summary Activity Area Hours Leadership Roles (LR) PDS Course (PDS) Civic Engagement (CE) Out-of-Class Learning (WSC) including workshops, seminars, & conferences TOTAL HOURS Corresponding Activity Numbers* / 30 hours / 30 hours / 40 hours / 30 hours / 100 hours *Taken from the following “Leadership Certificate Record of Activities” Content Area Individual (I) Group (G) Community (C) TOTAL HOURS Hours Corresponding Activity Numbers* / 25 hours / 30 hours / 45 hours / 100 hours *Taken from the following “Leadership Certificate Record of Activities” Ethics Statement I certify that the information in this application is true and complete to the best of my knowledge and I understand that inaccurate information may affect my status relative to the Leadership Certificate. I also understand that if, after receiving the Leadership Certificate, it comes to the attention of the granting parties that information I am presenting here is untrue or inaccurate, the Leadership Certificate will be withdrawn and all benefits forfeited. I also acknowledge that this application and supporting documents become the property of the University of Wisconsin system. Signature: ________________________________________________ Date: _____________________ Medical School Leadership Certificate Record of Activities Page # 1 of____Total Pages Name:_________________________________________________________ ID# ___________________________ Activity Dates Number Activity Description Activity Area* (Please circle Area) Content Area(s)** Hours Verification Submitted*** (Please circle Area) 1 LR 2 LR 3 LR 4 LR 5 LR 6 LR 7 LR 8 LR 9 LR 10 LR 11 LR 12 LR PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC PDS WSC CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C CE I G C *Activity Areas: LR – Leadership Roles, PDS-Required Course, CE – Civic Engagement, WSC – Out-of-Class Learning including workshops, research, seminars & conferences. **Content Areas: I – Individual, G – Group, C – Community. ***Verification information should be attached following the last page of the “Leadership Certificate Record of Activities” form and should identify the “Activity Number” clearly at the top of each submission. Please Initial Each Page Here: ________ Medical School Leadership Certificate Record of Activities Page # 2 of____Total Pages Name:_________________________________________________________ ID# ___________________________ Activity Dates Number Activity Description Activity Area* (Please circle Area) Content Area(s)** Hours Verification Submitted*** (Please circle Area) 13 LR PDS CE I G C WSC 14 LR PDS CE I G C WSC 15 LR PDS CE I G C WSC 16 LR PDS CE I G C WSC 17 LR PDS CE I G C WSC 18 LR PDS CE I G C WSC 19 LR PDS CE I G C WSC 20 LR PDS CE I G C WSC 21 LR PDS CE I G C WSC 22 LR PDS CE I G C WSC 23 LR PDS CE I G C WSC 24 LR PDS CE I G C WSC Any questions, please contact the Center for Leadership and Involvement, Room 239 Red Gym, 716 Langdon Street, Madison, WI 53706 or by phone at 608-263-0365 or e-mail at [email protected] . Please Initial Each Page Here: ________ Medical School Leadership Certificate Record of Activities Page # 3 of____Total Pages Name:_________________________________________________________ ID# ___________________________ Activity Dates Number Provider/Activity Description Activity Area* (Please circle Area) (Please continue numbering) Content Area(s)** Hours Verification Submitted*** (Please circle Area) LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC LR PDS CE I G C WSC Any questions, please contact the Center for Leadership and Involvement, Room 239 Red Gym, 716 Langdon Street, Madison, WI 53706 or by phone at 608-263-0365 or e-mail at [email protected] . Please Initial Each Page Here: ________
