Fillable 2018-2019 IV-E BASW Application 9.17

Fill Online, Printable, Fillable, Blank 2018-2019 IV-E BASW Application 9.17 Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY, FRESNO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2018-2019 IV-E BASW Application 9.17

On average this form takes 43 minutes to complete

The 2018-2019 IV-E BASW Application 9.17 form is 16 pages long and contains:

  • 4 signatures
  • 16 check-boxes
  • 149 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fresno

BROWSE CALIFORNIA STATE UNIVERSITY, FRESNO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
California State University, Fresno Department of Social Work Education
Title IV‐E BASW Child Welfare Program
App
lication 2018
‐2019
Please Type
Deadline February 2, 2018
Personal Information
Last Name First Name Middle initial
Gender
Date of Birth Ethnicity
SSN Student ID Expected Graduation Date
Are you applying as a county employee? Yes No Are you applying for Full Time Part Time
Admittance into the Part Time program is limited to current employees of CWS, DSS, CDSS or Tribal agencies.
Personal Information
Street Address
City State
Zip
County of Residence How long? Are you a resident of CA?
Mobile Phone Email
Home Phone Work Phone
Mailing Address (if different from above)
Street Address City _____________________ State _______ Zip ________
PO Box City _____________________ State _______ Zip ________
Permanent Emergency Contact Information (preferably a different address)
Contact 1 Contact 2 Contact 3
Name
Relationship
Street
City, State, Zip
Phones
Emails
California State University, Fresno 1 Department of Social Work Education
Auto Insurance Information
Driver’s License State Issued Exp. Date
Automobile Insurance Company Policy #
Type of Coverage Exp. Date
Insurance Agent Name & Phone Number
Background
Have you ever been convicted of a misdemeanor or felony? If yes, please give date(s), location(s), and
penalties.
Convictions are evaluated for each position and are not necessarily disqualifying. All information is kept
confidential. Attach separate sheet if necessary
Citizenship & Veteran Status
Are you a US Citizen? If not, please provide a copy of your legal documentation.
Type
of Documentation Docum
ent
Number
& Exp.
Date
Does you legal documentation
permit
you to
work
post-
gr
aduation? Is
there
a
time
limit?
Country of Origin Ethnicity/
Race
Are you currently enlisted in any branch of the U.S. Military? Yes No If yes, please provide documentation.
Are you a Veteran of any branch of the U.S. Military? Yes No If yes, Length of time enlisted ________
Are you receiving Veteran Benefits? Yes No Please provide documentation.
Please Choose if Applicable:
Languages (other than English, include Sign Language)
Language 1 Spoken
1
Written 1
Language 2 Spoken
2
Written 2
Language 3 Spoken
3
Written 3
California State University, Fresno
2
Department of Social Work Education
Please List county agency? If not employed with County agency please skip
County and agency name _____________________________________________________________________
Agency Address
Job Title Agency Director __________________________
Task Area/Current Unit_______________________________ _________________________________________
Immediate Supervisor___________________________________ Supervisor’s Phone: ______________________
Length of employment. Year(s) __________________ Month(s) ______________
Employment History
Attach additional pages if necessary
Employer/Setting
Description of
Duties:
Dates: From: _ __ To: ___
Year(s): ___
Months: ________
Volunteer History
Agency/Setting
Attach additional pages if necessary
Description of Duties:
Dates: From: To:_
Year(s):
Months: _________
County Employment Information
California State University, Fresno 3 Department of Social Work Education
Please initial each statement indicating that you read, understand and agree to the following requirements for
the Title IV-E support:
If I am an employee of a county child welfare or social service agency, I agree to provide, as part of this
application, (1) letter of recommendation from my county supervisor/program manager, a letter of
recommendation from a past employer/teacher/etc. with my application, and upon acceptance a letter of support
from my county director indicating approval of my participation in the Title IV-E BASW Child Welfare Program
as a part-time student. This letter is to be submitted on or before the final due date;
If I am not a county or social service agency employee, I agree to provide, as part of this application, (3)
letters of recommendation from county personnel, professors, employment supervisors, or a combination of the
three to be submitted with my application on or before the final due date;
I agree to maintain good standing during full-time or part-time enrollment in the BASW Program and
complete the BASW curriculum. “Good Standing” is defined as having a GPA of 2.5 or above;
I agree to successfully complete my field placement in a children’s services agency and/or a public or non-
profit agency serving child welfare clients;
I agree to maintain use of an automobile, a valid driver’s license, and automobile insurance for bodily
injury at all times during my completion of this program;
I agree to be fingerprinted and to meet the criminal clearance requirements;
I understand that I am obligated to pay back this stipend/award support through one year of employment
after graduation in a public/Tribal child welfare or CDSS agency. If I am a county employee, I understand that I
must return to my supporting agency;
I hereby promise to comply with the conditions stated above. I will agree to the provisions of the sample
contract (attached) if granted the Title IV-E Child Welfare Stipend;
I hereby attest to the fact that I have never been convicted of a felony or a misdemeanor crime involving
harm to children. *Note: The criminal background clearance will disclose felonies and misdemeanors;
I hereby attest to the fact that I have never been discharged from employment at a county or other social
services agency due to violation of county code/merit system rules or violation of agency or professional code of
conduct and ethics.
Signature:
Print Name:
Date:
Affirmation
California State University, Fresno
4
Department of Social Work Education
click to sign
signature
click to edit
I hereby affirm that all information I have provided in this Title IV‐E BASW Child Welfare Program Application
is true and correct.
Student/Employee Signature:
Date:
Please continue to Section II of the Application, attached. All parts of the Application must be submitted on or
prior to the final due date.
Please mail your application along with your appropriate support letters, sealed and signed on the back of the
envelope to:
CAMPUS ADDRESS:
Title IV-E BASW Social Work Training Program
Department of Social Work Education
5310 North Campus Drive, M/S PH 102
Fresno, California 93740-8019
Attn: Maggie Armistead, MSW
Title IV-E BASW Program Coordinator
Fresno State
9.12.17
California State University, Fresno Department of Social Work Education
5
Affirmation
click to sign
signature
click to edit
Directions: On separate sheet of paper, please respond to the following set of questions. Make sure that
you respond to each question and include your name on each page. Please use headers to organize your
responses and present your work in a brief and concise manner. Your entire response must be no longer
than 5 double- spaced typed pages.
1. Please describe your current knowledge and understanding of the child welfare system and
your interest in working with children and families.
2. What personal characteristics do you have that will help you work successfully in this field?
3. As you think of the diverse clients represented in public child welfare practice, how do you
feel these individuals are similar or different from you?
4. What are the necessary steps you would take in dealing with challenges when faced with
personal or family while meeting the expectations of the IV-E Program and the county child
welfare agency field placement?
5. What is your understanding of the level of commitment associated with the Title IV-E BASW
Child Welfare Stipend Program?
6. In reference to you career goals, where do you see yourself within the next five years?
For Non- County Employees: Three letters of “Reference/Support Forms” are required. These forms may be
completed by a professor, advisor or work supervisor. No personal references are permitted. Please
download this form from the Title IV-E website http://www.fresnostate.edu/chhs/social-work/degrees-
programs/titleive/
and ask your reference to seal the letter in an envelope, sign across the seal and return
the sealed letter to you to be included with your application. See attached sample.
For County Employees: Three reference forms are required, one from your County Supervisor/Program
Manager, One completed by a professor, advisor or past employer, and (upon acceptance) One from your
County Director to indicate Approval of your
participation within the Title IV-E BASW Child Welfare
Program. No personal references are permitted. See attached sample.
Ask your references to seal the letter in an envelope, sign across the seal, and return the sealed letter to
you to include with your application.
Check Off List:
Section II
Title IV-E BASW Standard Application
Essay Question for Personal Statement
Title IV-E BASW Application
Reference Letter #1
Reference Letter #2
Reference Letter #3
Personal Statement
If not a U.S Citizen: Legal Documentation
Title IV-E BASW Application
Personal Statement
Reference Letter- Agency Supervisor/Program Manager
Reference Letter- Advisor, Professor, Past Employer
Letter of Support- County Director
Upon Acceptance in IV-E Program
California State University, Fresno
6
Department of Social Work Education
FRESNO STATE
DEPARTMENT OF SOCIAL WORK EDUCATION
TITLE IV-E BSW CHILD WELFARE PROGRAM
BSW REFERENCE FORM
DATE:
APPLICANT NAME:
REFERENCE NAME:
The above named individual is applying for acceptance into the Title IV-E BSW Child Welfare Stipend
Program for the academic year of at CSU/UC at _____________________.
The curriculum for this program is designed to educate and prepare individuals for a beginning level of
professional practice within the field of Public Child Welfare. We are seeking individuals who possess a
genuine and sincere interest in and commitment to working with at risk children and families within the child
welfare system. Because of the challenging nature of this field of practice, it is vitally important that
individuals demonstrate the qualities and skills necessary to problem solve and meet the special critical needs
present in diverse populations. We are therefore seeking those candidates who strongly represent and adhere to
the principles reflected in the NASW Code of Ethics to maintain the standards of the profession of Social
Work.
This student has selected you as a source of reference. We are depending upon you to provide us with the
information to help us access this student’s suitability to meet the expectations of this program. We strongly
believe that it is unethical to admit an applicant who is not committed to working with children and families,
whose ability to successfully complete the program is doubtful, or who is not suited for the professional role of
Child Welfare Worker. Your thoughtful evaluation of this student’s potential and readiness for professional
practice and specialization in the field of child welfare is very important to us.
We thank you in advance for your assistance in this matter and ask you to please respond to the following
questions. If you need more space, you are welcome to expand your responses on a separate sheet.
1. How long and in what capacity have you known the applicant?
years months
(Specify capacity: supervisor, professor, Advisor, etc.)
2. Please explain what you consider to be the applicant’s major areas of strength as a candidate
for the specialization in child welfare practice?
3. Please explain what you consider to be the applicant’s area of limitation(s) that need to be
strengthened to foster success in working with children and families?
4. Using the following scale from 0 to 3, (0= below standard, 1= average, 2= above average,
and 3 = exceptional), please address the applicant’s capacity in the following areas: (Please
use the * symbol if you are unable to evaluate the area based upon lack of
opportunity).
Questions:
0-3 or *of
unknown
Demonstrates intellectual ability
Ability to respect and work with diverse populations
Sensitivity to the needs and feelings of others
Ability to establish positive working relationships with others
Demonstrates professional work habits
Commitment to values & ethics of the social work profession
Ability to be accountable for professional practice in working with others
Willingness to accept direction, recommendations, and/or supervision
Demonstrates a positive level of common sense/judgment
Demonstrates acceptable levels of emotional stability
Demonstrates ability to problem solve utilizing positive strategies
Ability to complete task/assignments in a timely manner
Ability to solicit help/assistance when needed
Ability to effectively communicate in writing
Ability to effectively communicate verbally
Applicants overall potential for child welfare social work
5. Recommendation: (Please check one):
I am unable to make a recommendation at this time. Please explain in
“Comments” section on next page.
I do not recommend this applicant for acceptance into the Title IV-E Program.
California State University, Fresno
8
Department of Social Work Education
I recommend this applicant with some reservations, but if admitted, I believe the
applicant would benefit from study in the program. Please explain your reservations in
“Comments” section below.
I recommend this applicant for acceptance and believe this person will perform at a
standard level of performance comparable to most undergraduate students.
I highly recommend this applicant for acceptance and believe this person will
perform at a level above most undergraduate students.
I most highly recommend this applicant for acceptance and believe this person will
perform at an exceptional level above most undergraduate students.
6. Additional Comments:
Please Print Name of Reference: Date:
Signature of Reference:
Name of School or organization:
Address:
Title: Phone #:
Email Address:
Special Note: Reference Forms will not be accepted without a signature and a date. All
forms are due upon application deadline.
Thank you for your time and commitment in fostering quality in social work practice.
Please place your letter in an enclosed envelope, seal the envelope and sign your name across the
seal and return the sealed letter to the applicant.
Fresno State
9.17
click to sign
signature
click to edit
SAMPLE LETTER OF SUPPORT/APPROVAL
(COUNTY EMPLOYEE ONLY)
(Please give to the County Director of the Dept. of Children and Family Services to prepare
the letter of support using their own letterhead paper)
TO: Maggie Armistead, MSW
Title IV-E BASW Coordinator
Department of Social Work Education
5310 N. Campus Drive, M/S PHS-102
Fresno, CA 93740-8019
is an employee of ________________ County, who
works within the (Name of Department or Task Unit). Mr. or Ms. has informed me of their
desire to return to school to pursue a Bachelor of Arts Degree in Social Work at California State
University, Fresno with a specialization in Child Welfare Practice.
Mr./Ms. (Name of applicant) has been employed with (Name of County/Department/Unit) since
(date of employment). She/he has expressed a sincere interest in working with at risk youth and
their families and plans to seek employment within the Department of Children and Family
Services Department upon completion of all degree requirements. According to ’s
program manager, (please state their name), he/she is aware that this employee will be required
to complete the payback requirements of the child welfare stipend program by securing
employment within a child welfare setting. As Director of County Department of
Children and Family Services, I have consulted with this employee’s immediate supervisor and
program manager and we collectively offer this letter of support for this employee whom we find
to be committed to county services and believe this person to be a good candidate for the child
welfare stipend program. We are not however at a point where we can guarantee a position for
this employee within the child welfare agency at the time when this employee plans to graduate
from the program. We are prepared to offer our acknowledgement and support of this worker’s
educational pursuits and look forward to their continued employment with County in
the near future.
If you have any further questions, you may contact me at .
Sincerely,
__________________________________
Director,
Department of Children & Family Services
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2018-2019 IV-E BASW Application 9.17

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 June 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document