Fillable BSW Hybrid Application 2020 Fillable APPLICATION FOR ADMISSION

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BSW Hybrid Application 2020 Fillable APPLICATION FOR ADMISSION

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BSW Hybrid Program Application for Admission
Page 1 of 2
REV 12/30/19
Name
Date PSU Student ID No.
Address
City State Zip code
Phone (Home) (Work) (Cell)
PSU Email Other Email:
Anticipated City of Residence During Program _____________________________________________
Emergency Contact Person and Phone Number:
Educational Experience: (Community college and/or university, degree completed, etc.)
List all volunteer, work, and military experience. Please be aware that there is special attention paid to
experience in social work or related fields (including paid employment and volunteer service). Please print
out as many pages of this as needed to include all of your experience. List most current experience first.
Agency Name/Address:
Date Start
Position Held:
Date End
Describe Duties:
Total
Months
Supervisor’s Name:
Paid ____ Volunteer ____
Hrs/wk
Total hours (months x 4 x hours per week)
Agency Name/Address:
Date Start
Position Held:
Date End
Describe Duties:
Total
Months
Supervisor’s Name:
Paid ____ Volunteer ____
Hrs/wk
Total hours (months x 4 x hours per week)
Agency Name/Address:
Date Start
Position Held:
Date End
Describe Duties:
Total
Months
Supervisor’s Name:
Paid ____ Volunteer ____
Hrs/wk
Total hours (months x 4 x hours per week)
Are you a transfer student? No Yes What college?
Page 2 of 2
REV 12/30/19
Have you taken the following courses?
Any college level courses online: No In Process Yes How many? ______
Required prerequisites:
Psychology No In Process Yes Grade received: ______
Sociology No In Process Yes Grade received: ______
Human Development No In Process Yes Grade received: ______
Please list any languages that you speak fluently: ____________________________________________
Are you a First-Generation college student? Yes No
(A first-generation college student is defined as a student whose parent(s)/legal guardian(s) have not completed a bachelor’s
degree at a four-year college or university.)
Are you interested in a fully online BSW Program option: Yes No
(Depending on interest we may offer a fully online program starting fall 2020.)
THESE QUESTIONS ARE OPTIONAL
In compliance with a policy of the U. S. Department of Health and Human Services, the University must seek to identify the
ethnic background of applicants for admission. The School of Social Work must also supply additional information to the
Council on Social Work Education, its accrediting organization. You are encouraged to supply the following information but
may decline without prejudicing your application.
Date of Birth:_________________ Veteran Status: ________________________
Gender:
___ Agender
___ Genderqueer
___ Man
___ Woman
___ Transgender
___ Trans Man
___Trans Woman
___ Questioning or Unsure
___ Non-Binary, including gender
fluid and gender non-conforming
___ Identity or Identities not listed
___ Prefer not to answer
Ethnic Origin: (Please circle all that apply.)
1. Asian/Pacific Islander 4. Native American (Indian, Alaskan) Tribal Affiliation: ________________________
2. Black, Non-Hispanic 5. White, Non-Hispanic
3. Hispanic 6. Other (please specify) __________________________________________________
Criminal Conviction Statement Portland State University’s School of Social Work takes seriously the
need to protect the public, as well as to provide appropriate opportunities to individuals wishing to enter
the social work profession who have criminal records. We are committed to assuring that individuals who
might pose a threat to any client group or practice setting be prevented from causing harm. We are also
committed to the value and belief that any particular arrest or criminal conviction history is not in and of
itself indicative of a person’s readiness or potential to enter into and contribute to the social work
profession. The School of Social Work makes no presumptive judgments regarding the criminal history of
a student and potential field placements. This policy is intended to ensure that the School of Social Work
field team will make a reasonable effort to identify a suitable field agency that will provide a placement for
a student with a criminal record. Students need to know that in fulfilling this effort, certain types and
calendar dates of criminal convictions may result in some agencies declining to offer them a field
placement. In some instances, it may not be possible for the field team to find a placement willing to
interview or accept the student. In such a case, it is likely that the student will be unable to complete the
BSW or MSW program.
To the best of my knowledge, the information in this application is accurate and complete.
Signature: _____________________________________________ Date: ___________________
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BSW Hybrid Application 2020 Fillable APPLICATION FOR ADMISSION

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Completed 13 February 2020

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