Fillable BSW Field Application Revised 12.2013 (Darton State College)

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BSW Field Application Revised 12.2013 (Darton State College)

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The BSW Field Application Revised 12.2013 (Darton State College) form is 7 pages long and contains:

  • 8 signatures
  • 27 check-boxes
  • 104 other fields

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File type: PDF

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Revised 10/2013
ALBANY STATE UNIVERSITY
Department of Social Work
504 College Drive Albany, Georgia 31705
Telephone: (229) 430-2974 Fax: (229) 903-1949
Directions: Complete this application by typing your information directly into the fields indicated on
your computer screen. Print three copies of this application. Attach a minimum of ƚŚƌĞĞ wallet size
photos t
o
all three copies of the applicatio
n.
E^tmembership and liability insurance must be applied for and processed prior to entering field
placeme
nt. Proof of NASW membership and liability insurance must be given to the Field Coordinator no
later than the 13
th
week of the semester in which you applied for field placement.
PERSONAL DATA:
NAME: DATE:
LAST FIRST MI
CURRENT MAILING ADDRESS:
Number Street Apt. # City State Zip
PERMANENT MAILING ADDRESS:
Number Street Apt. # City State Zip
TELEPHONE: E-MAIL:
Home Work/Cell
RACE: GENDER: M F RAM ID #:
EMERGENCY CONTACT:
NAME: RELATIONSHIP:
LAST FIRST MI
ADDRESS:
Number Street Apt. # City State Zip
TELEPHONE: E-MAIL:
Home Work/Cell
ACADEMIC DATA:
School/ University Address
School/ University Address
School/ University Address
DEPARTMENT OF SOCIAL WORK
APPLICATION FOR FIELD INSTRUCTION
SEMESTER (Check One): Fall Spring
Revised 10/2013
Total Number of Hours Completed:
GPA: Cumulative: Social Work:
EMPLOYMENT:
Are you currently employed? Yes No If yes, number of hours worked per week:
Do you plan to continue to work during field placement? Yes No
If yes, what are your plans for managing employment and 32 hours per week in field placement?
TRANSPORTATION
Do you have an automobile at your disposal? Yes No
Do you have a valid Georgia driver’s license? Yes No License Number:
Do you have any outstanding driving violations? Yes No
If yes, please explain:
If transportation is going to be problematic, please explain:
List courses to be taken while in Field Placement including SOWK 4470 and 4471:
COURSES AND NUMBERS HOURS COURSES AND NUMBERS HOURS
Total Number of Hours:
List courses in which you are presently enrolled:
COURSES AND NUMBERS HOURS COURSES AND NUMBERS HOURS
Total Number of Hours:
Revised 10/2013
BACKGROUND CHECK
NOTE: Most social service agencies complete background checks prior to students starting an internship, please
answer the following questions very honestly. (If you have had any court actions, submit the disposition with the
application.)
Have you ever been charged with a felony? Yes No
If yes, what were the charges?
Were you convicted of the charges? Yes No
If yes, explain the outcome.
FIELD PLACEMENT INFORMATION
Do you have personal obligations that would interfere with field placement? Yes No
If yes, explain.
Do you speak a second language? Yes No If yes, list.
Field Placement Interest (Rank in order of preference using numbers 1 through 12.)
Gerontology
Public Welfare
IV-E Child Welfare
Hospice
Medical Social Work
Mental Health
Corrections
Domestic Violence
Mental Retardation
Substance Abuse
School Social Work
Other (Specify)
Geographical Location for Placement (Rank in order of preference)
1.
2.
3.
4.
List other factors that could be considered in determining the best field placement assignment for you.
Revised 10/2013
NOTE: On the attached sheet, complete a biographical sketch of yourself. It must be typed and it must include
the following information:
• Name
• Where you reside within the 24 county catchment areas of Albany State University
• Work experiences
• Volunteer experiences (separate class volunteer experiences from others) and description of how the
experiences were related to social work skills
• Relevant life experiences
• What skills you hope to develop while in field placement
• What you see yourself doing three to five years from graduation
• Your ultimate career objective
• What you expect from your field experience
• Any other information about yourself or comments you would like to convey to a potential field
instructor
Please make a special effort to complete this biographical sketch using the appropriate language as a copy of
this for may be mailed to the potential field instructor as an introduction on your behalf. Please sign below as
authorization for your information to be shared.
AUTHORIZATION:
I hereby authorize release of my biographical sketch and other pertinent information necessary to agencies
considering me for field placement and to my field placement agency.
Student’s Signature Date
Print Name
ĞƉĂƌƚŵĞŶƚŚĂŝƌ/Field Coordinator Signature  Date
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Revised 10/2013
BIOGRAPHICAL SKETCH
Revised 10/2013
(Use as additional page for biographical information)
Revised 10/2013
FIELD PLACEMENT RECOMMENDATION: Print and clip (do not staple) to applications.
is recommended as a candidate for field placement.
Student’s Name (Please Type)
Upon the completion of the presently enrolled courses listed on page 2.
Only if the following items have been taken satisfied:
Advisor/ Chair’s Signature Date
Student’s
Signature Date
is not recommended as a candidate for field placement.
Student’s Name
Associate Degree not on transcript
Has not met Social Work Curriculum requirements
Has not completed area
Advisor/ Chair’s Signature
Date
Student’
s Signature Date
AGENCY ASSIGNED TO FIELD INSTRUCTOR DATE
Field Coordinator’s Signature Date
Chair’s Signature
Date
OFFICIAL USE ONLY
/
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BSW Field Application Revised 12.2013 (Darton State College)

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Completed 22 July 2020

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