Media Literacy: Potential Student Profile
First Name
Last Name
St. Address
City
State
Alabama
Outside US / Canada
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Is
Northwest Territories
Nova Scotia
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Prince Edward Island
Province du Quebec
Puerto Rico
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon Territory
Zip/Postal Code
Country
Argentina
Australia
Austria
Bahamas
Belgium
Bolivia
Brazil
Canada
Chile
China
Colombia
Costa Rica
Croatia
Cuba
Czech, Rep.
Denmark
Dominican, Rep.
Ecuador
Egypt
El Salvador
Finland
France
Germany
Great Britain
Greece
Guatemala
Honduras
Hong Kong
India
Ireland
Israel
Italy
Jamaica
Japan
Luxembourg
Mexico
Morocco
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Paraguay
Peru
Poland
Portugal
Puerto Rico
Russia
Saudi Arabia
South Africa
Spain
Sweden
Switzerland
Taiwan
Turkey
United States
Uruguay
Venezuela
Work Phone
Home Phone
Email
Fax
Undergraduate Degree
University
Date Completed
Current Job
Future Job Change?
Teaching History/ Experience
Which of the following are you most interested in?
36 Hour Graduate Program in Media Literacy
18 Hour Certificate of Completion in Media Literacy
1, 2, 3 courses in Media Literacy
Are you interested in taking one or more courses online?
Yes
No
Have you had prior experience with online classes?
Yes
No
We can provide affordable housing during the media literacy summer sessions, usually held in July. Would you be interested incoming to the Boone campus for July classes?
Yes
No
Select 3 of the following that best sum up your areas of interest:
Media design/production
Media effects on children/teens
Media and public health
Media democracy/citizenship
Media Literacy and Curriculum Development
Media Literacy K-6
Media Literacy and Middle School
Media Literacy High School and BEYOND
Media and Violence
Emerging Technologies
Media and the Arts
Media and Faith Based Education