Fillable 2018-2019 MSW Application

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2018-2019 MSW Application

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The 2018-2019 MSW Application form is 5 pages long and contains:

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  • 4 check-boxes
  • 140 other fields

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File type: PDF

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California State University, Fresno
Title IV-E MSW Child Welfare Program
Application 2018-2019
Department of Social Work Education
Please Type Application
Deadline March 2, 2018
Personal Information
Applying as (Check all that apply): 1
st
Year MSW 2
nd
Year MSW Full Time Part Time
Last Name _____________________________First Name _____________________________Middle initial _________
Gender_____________ Date of Birth ________________ Ethnicity ___________________________________________
SSN _________________________ Student ID _____________________Expected Graduation Date ________________
Please Check: Single Married Separated Divorced Domestic Partnership Widowed
Previous Name if used _______________________________________________________________________________
Are you a Title IV-E BASW Grad? Yes No If so, what school? ___________________________________________
Date of graduation______________ Have you completed your payback? Yes No
Current Home Address
Street Address _________________________________City ______________________State __________ Zip __________
County of Residence ____________________________ How long? __________ Are you a resident of CA? Yes No
Fresno State Email __________________@mail.fresnostate.edu Non-Fresno State Email __________________________
Mobile Phone _____________________ Home Phone _____________________ Work Phone _____________________
Mailing Address (if different from above)
Street Address ______________________________City ______________________State _______ Zip ________
PO Box ____________________________________
Permanent Emergency Contact Information (preferably a different address, a minimum of 2 are required)
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. Attach separate sheet if necessary.
(All information is kept confidential)
Citizenship & Veteran Status
Are you a US Citizen? _________ If not, please provide a copy of your legal documentation.
Type of Documentation _______________________________Document Number & Exp. Date _______________
Does you legal documentation allow you to work post-graduation?
Yes No Is there a time limit? Yes No
Country of Origin _______________________________ Ethnicity/ Race__________________________________
Please check if applicable: Veteran Disabled Veteran Foreign Student Resident Immigrant
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
County Employment Information
Please complete this section. Attach additional pages if necessary.
Resumes will not be accepted in lieu of this section, but may be
attached to the application.
Are you currently employed in public child welfare or other county social services division? No Yes
If no, please skip this section. Attach additional pages if necessary
County and agency name _____________________________________________________________________
Agency Address ______________________________________________________________________________
Job Title ____________________________________________ Agency Director __________________________
Current Unit _________________________________________ Immediate Supervisor _____________________
Supervisor’s Phone # _______________________ Length of employment Year(s) ________Month(s) ________
Are you currently seeking educational leave or letter of support from county child welfare or other social
services? ________
A letter of support will be requested upon official acceptance
Internship History
Attach additional pages if necessary. Please note if your employment or volunteer work was full or part time.
Agency name _____________________________________________________________________
Internship Setting ______________________________________________________________
Job Title __________________________________ Length of internship Year(s) ________Month(s) ________
Description of Duties:
Dates ____________________________________________________________________________________
California State University, Fresno 3 Department of Social Work Education
Education
Related Employment History
Please complete this section. Attach additional pages if necessary. Resumes will not be accepted in lieu of
this section, but may be attached to the application.
Employer/Setting _____________________________________________________________________
Job Title __________________________________ Length of employment Year(s) ________Month(s) ________
Description of Duties:
Dates of employment ________________________________________________________________________
Volunteer History
Attach additional pages if necessary
Agency/Setting _____________________________________________________________________________
Year(s) ____________ Month(s) ____________
Description of Duties:
Dates _____________________________________________________________________________________
Undergraduate Degree: BA BS Major __________________________________________________
Institution ______________________________________________ Graduation Date:_________________
University attended for graduate school __________________________________________________________
Do you have other graduate degree(s)? Yes No
(Please Identify) ____________________________________________________________________________
California State University, Fresno 4 Department of Social Work Education
SELF-GENERATED ID-CalSWEC
W
e are interested in linking the findings as they apply to Title IV-E recipients from this study with earlier findings
generated from the anonymous surveys given to MSW students at the start and upon completion of their studies. We
hope that this linkage will advance our understanding of the influences of students.
In these spaces write the first three letters of your mother’s maiden name.
(example: If her name is/was Alice Smith, the letters are SMI)
_____ _____ _____
In these spaces write the first three letters of your mother’s first name.
(example: If her name is/was Alice Smith, the letters are ALI )
_____ _____ _____
Note: If the name has fewer than three letters, fill in the letters from the left and add 0 (zero) in the remaining space(s)
on the right. [example: If her name is/was Lu We, the codes would be LU0 and WE0)
Pr
ogram Agreement for Title IV-E Participation
I understand that this award requires that I complete all of the following requirements:
(1)
(2)
Completion of personal Statement addressing your child welfare interest.
Maintain “good standing” during full-time and/or part-time enrollment in the MSW Program and
complete the MSW curriculum. “Good standing” is defined as having a GPA of 3.00 or above.
(3) Successfully complete and receive a grade of CREDIT in two years of field internship placement. One
placement will be in a public child welfare agency and the other placement will be in either a different
public agency or a non-profit agency that serves IV-E eligible children and families.
(4) Maintain automobile insurance while enrolled in internship in the MSW program.
(5) Complete required Specialized Child Welfare Curriculum including:
(1) SW 278 Advanced Child Welfare Practice.
(2) Title IV-E Integrative Seminars, or other trainings.
(3) SW 298 or 299 – Master’s Thesis or Project with focus on child welfare practice population, service
delivery system, and issue or topic area.
(4) Attendance and participation in Child Welfare Symposium.
(5) Participation in Title IV-E surveys as requested by CalSWEC.
(6) Participation in Professional Mock Interviews.
(6
) Obligation to pay back this award as designated in CalSWEC contract. This requires a two (2) year
employment commitment in a public child welfare agency if I am a full-time or a part time student.
I hereby attest that I have never been convicted of a felony crime or any crime involving harm to children. I
hereby attest 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 codes of ethics. Failure of
any of the above stated requirements could result in a suspension of your payment of financial support.
I h
ereby affirm that all information provided in this Title IV-E Master of Social Work Child Welfare Program
Application is true.
St
udent Signature: ______________________________________________
Print Name: ___________________________________________________
Date: ________________________________________________________
California State University, Fresno 5 Department of Social Work Education
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Personal Statement Addressing Child Welfare Interest
This statement will be utilized for evaluating your knowledge of child welfare practice, to assess your
commitment to the child welfare field and understanding of your career choice. A maximum 3-5 page
paper, typewritten and double-spaced, is required. Please respond in a concise manner reflective of your
knowledge and experience in the child welfare arena. Please provide illustrations of your experience
where appropriate.
1. Briefly explain your understanding of public child welfare services. Include your understanding of
current critical issues in child welfare practice.
2. Discuss your experiences, both personal and professional, that have prepared you for work in a child
welfare agency.
3. Cite examples of your experiences working with culturally diverse populations and indicate areas of
strength and areas needing growth in which you would like to develop further expertise.
4. Describe your interest/experience in working with children and families within the child welfare
system.
5. Discuss your ability to conduct a regional and statewide employment search in public child welfare.
6. Upon graduation, once you receive your MSW degree, where do you see yourself in the next five
years? What are your long term goals?
Thank you for your interest in California State University, Fresno’s Title IV-E Master of Social Work
Child Welfare Program.
Rev: 09/12/17
California State University, Fresno 6 Department of Social Work Education
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2018-2019 MSW Application

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Completed 1 June 2020

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