Have you ever been convicted of a felony or misdemeanor as an adult? Yes No
Has any governmental agency ever substantiated allegations made against you for physical, mental or emotional
abuse or neglect, sexual abuse, or exploitation of (1) a child, (2) a resident of an adult care home, medical care
facility, psychiatric hospital or state institution, or (3) an adult?
Yes No
If you answered yes to either of the above, please attach a narrative statement of explanation.
Answering “yes” does not automatically disqualify you for admission to the BSW program. However,
depending on circumstances, it may affect your ability to be placed in a field practicum which is necessary to
complete the BSW program. Please contact the Field Practicum Director if you have any questions.
I understand that prior convictions, diversions or pending charges may affect my ability to be placed in a field
practicum which is necessary to complete the BSW program. This means that while you may be admitted to the
program, you may not be able to complete the degree if there is something in your background that would
prevent you from being placed in a field practicum. Many agencies require background checks. Some criminal
charges may affect your ability to be licensed in the State of Kansas.
Practicum Manual Acknowledgement
I have been advised to read the Wichita State University School of Social Work Field Practicum Manual,
located at http://webs.wichita.edu/?u=socialwork&p=/practicum/practicum_manual/. I agree to follow the
expectations outlined in that manual throughout the course of my field placement experience.
Disabilities / Modifications
Wichita State University is committed to providing equal access to employment, educational programs, and
activities for students with disabilities. The University recognizes that students with disabilities may need
accommodations to have equally effective opportunities to participate in or benefit from University educational
program, services and activities and will make reasonable modifications to the environment, policy and practice
and/or provide auxiliary aids and services when the Office of Disability Services determines such modifications
are needed for equal access.
Reasonable accommodation will be considered and may be made to qualified students who disclose a disability,
so long as such accommodation does not significantly alter the essential requirements of the curriculum and the
training program, or significantly affect the safety of others.
I also understand, and acknowledge that it is my responsibility to notify Wichita State University if I am in need
of an accommodation. I further understand and acknowledge that it is my responsibility to notify Wichita State
University if there is any reason I cannot meet the expectations of the Social Work Program, with or without
reasonable accommodations.
I certify that the information on this application form is accurate and complete.
Signature of applicant (type name if submitting electronically) Date