Fillable DEPARTMENT OF SOCIAL WORK BSW PROGRAM APPLICATION FOR (Darton State College)

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DEPARTMENT OF SOCIAL WORK BSW PROGRAM APPLICATION FOR (Darton State College)

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ALBANY STATE UNIVERSITY ALBANY, GA 31705
DEPARTMENT OF SOCIAL WORK BSW PROGRAM
APPLICATION FOR ADMISSION
Telephone: (229) 430-2974 or (229) 430-2870 PLEASE TYPE AND SIGN APPLICATION
Date Applied: ______________________ Part-time Full-time
BIOGRAPHICAL DATA:
NAME: RAM ID: _______________________________
(Last) (First) (Middle)
Permanent Address: ___________________________________________________________________________________________
(Street) (City) (State) (Zip)
Local Address: _______________________________________________________________________________________________
(Street) (City) (State) (Zip)
Local Phone: __________________________________________ Cell Phone: _____________________________________
(Area Code) (Number) (Area Code) (Number)
Indicate Semester and Year Applying For: Fall: ________ Spring: _______ _________________________________________
(Year) (Year) (E-mail address)
I have completed 45 to 60 hours of college course work with a minimum of 2.5 GPA and am applying as a:
Freshman who declared Social Work as a Major
Transfer Student with an AA from: ________________________________________________________________
Major Change (ASU): Current Major ______________________________________________________________
Transfer Student from: __________________________________________________________________________
Former Social Work Student Returning: Last Year/Semester in School ____________________________________
Social Work Student who did not complete Field Practicum
Student Seeking Second Bachelor Degree: Identify First Degree: _________________________________________
Other (Explain) _______________________________________________________________________________
____________________________________________________________________________________________________________
ACADEMIC HISTORY: List all colleges and/or universities attended:
__________________________________________________________________________________________
College Location Dates Hrs.
____________________________________________________________________________________________________________
College Location Dates Hrs.
____________________________________________________________________________________________________________
College Location Dates Hrs.
____________________________________________________________________________________________________________
College Location Dates Hrs.
Degree Awarded:
A.A Date Awarded: __________ Institution: _________________________ G.P.A. ______
B.A./B.S. Date Awarded: __________ Institution: _________________________ G.P.A. ______
Other Date Awarded: __________ Institution: _________________________ G.P.A. ______
Which of the following courses are you taking now or have you completed? Indicate the semester, year
(e.g. Fall 2000), and grade. If you are currently taking courses that are listed, indicate by answering “now”.
Course No.
Course Name
Semester/Year
Grade
Biology I
Biology II
History
U.S. & Georgia Government
Introduction to Psychology
Introduction to Sociology
Urban Social Problems
Basic Statistics
World Literature I
SOWK 1385
Careers in Social Work
SOWK 2411
Introduction to Social Work
SOWK 2310
Self-Awareness
__________________________________________________________________________________________________
EMPLOYMENT INFORMATION:
Are you currently employed? Yes No Full time Part time Work Study
Will you be employed while enrolled at Albany State University? Yes No
If yes, will you be employed part time or full time throughout your educational process?
Full time Part time
Have you had any paid Social Work Experience? Yes No
Have you had any volunteer experience in a social service agency? Yes No
If you answered yes to experience(s) in a paid or volunteer setting, give an overview of the experience(s):
CRIMINAL HISTORY
Have you ever been arrested? Yes No Felony/Felonies? Yes No
If yes to either question, were you convicted: Yes No
If yes to the conviction, what was the charge? _____________________________________________________________
Please explain the disposition of the case on the last page, detach and place in an envelope, seal, sign and staple to
application.
Have you ever been arrested for a misdemeanor or misdemeanors? Yes No
If yes, what was the charge? ___________________________________________________________________________
Please explain the disposition of the case on a separate page, and place in an envelope. Seal, sign and staple the
envelope to your application.
DRUG AND ALCOHOL HISTORY
Are you currently or have you ever been in a Drug and/or Alcohol Treatment or Detoxification Center as a client? Yes No
If yes, explain: _____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Dates of Treatment(s): _______________________________________________________________________________
Name and Address of Facility: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Did you complete the treatment(s) prescribed? Yes No
If no, please provide an explanation: ____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EMOTIONAL/MENTAL HEALTH HISTORY
Have you ever participated in any type of counseling/psychotherapy? Yes No
If yes, what was the nature of the counseling/psychotherapy problem? (Please do not give in-depth details; if you see the
need to give specific details attach additional confidential information in a sealed envelope.)
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been hospitalized for any type of emotional or mental condition(s)? Yes No
If yes, please provide the following information for each time you were hospitalized (additional sheets may be attached).
Hospitalization Date(s): ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ADMISSION STATEMENT:
As a part of your application for admission to the BSW Social Work Program, you are to write a statement which
addresses the five areas listed below. This statement will be used to assist the BSW Social Work Admissions Committee
in their decision making process in reference to your application. Your typed admission statement is to be attached to
your application. The Admission Statement should be from three to five pages and well written, in APA format.
• Discuss the major reasons for your interest in the Social Work profession.
• Describe some of the successes you have achieved in school, employment, and in your personal life.
• Describe any barriers you have had to overcome while pursuing your educational, employment, or personal goals.
• Describe any experiences that you have had while working with people in which you felt you were able to use a
skill you thought at the time was related to the Social Work profession.
• Note previous experiences that made you feel that you could effectively provide services to individuals from
diverse populations reflecting religious, racial, ethnic, physical, socio-economic, gender, and sexual orientation
differences.
I certify that the information on this application is true and valid.
_____________________________________________________ _________________________
Signature Date
____________________________________________________
Type Name
**************************************************************************************************
OFFICIAL OFFICE USE (Do not sign below until interviewed)
STATEMENT OF UNDERSTANDING:
I understand that the Social Work Major Curriculum requires sixty (60) credit hours in upper-division courses,
including a twelve (12) hour Field Placement and a three (3) hour Integrative Seminar. I also understand that I would
need to join the National Association of Social Workers (NASW) when I am in Social Work 2412, and that my
membership should be in place prior to entering field placement. I have been advised that I have to purchase Professional
Liability Insurance prior to entering field placement, and that cannot be done if I am not a member of NASW. I further
understand that I will need to make a Formal Application of the BSW Social Work Program for field placement by the
end of the third week of the semester prior to being assigned to an agency. While I shall be consulted as to my interest
and choice of location for field placement, I am aware that my preference/choice may not be possible.
I understand that I must have an institutional grade point average (GPA) of 2.50 to be considered for admission
into the Social Work Program. Once admitted, I must maintain a minimum 2.50 GPA to be assigned in field
placement. The Social Work Program Admission’s Committee has advised me that I need to maintain a “B” or better
in all Social Work Core Requirements to successfully complete this undergraduate program and be considered for
graduate school.
Date Interviewed: ____________________________
____________________________________________ __________________________________________
Student Signature Committee Chair Signature
Date Application Received: _______________ Received by: ________________________________________
COMMITTEE’S DECISION: ___________ Accepted _______ Rejected ________Accepted Conditionally
Date Director Received: _______________________________ _______________________________________
Chair’s Signature
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ALBANY STATE UNIVERSITY
DEPARTMENT OF BSW SOCIAL WORK PROGRAM
STUDENT PERSONAL DATA
PLEASE TYPE AND SIGN APPLICATION
CHECK ONE: Undergraduate Transfer Student Date of Transfer
CHECK ONE: Fall Semester Spring Semester
CHECK ONE: Full-time Part-time
Personal Data:
Name: RAM ID: _______________________
(Last) (First) (Initial)
Local Address: _____________________________________________________________________________________
No., Street, Apt. City State Zip
Permanent Address: _________________________________________________________________________________
No., Street, Apt. City State Zip
Telephone: ________________________________________________________________________________________
(Home) (Mobile) (Place of Employment)
Sex: Male Female Birth Date: Age:
Marital Status: Single Married Divorced Separated Widowed
Are you a U.S. Citizen: Yes No
Do you require handicapped accommodations? Yes No
Do you require another service under the ADA or 504.B? Yes No
CLASSIFICATION: Freshman Sophomore Junior Senior
List Colleges/Universities Attended:
Name of School
City & State
Date
ETHNICITY:
African-American Asia Caucasian Hispanic (Not Mexican-American)
Mexican American Native American Puerto Rican Other (Specify)
EMERGENCY CONTACT:
NAME: _________________________________________________ Relationship: _______________________________________
Telephone: _________________________________________________________________________________________________
(Home) (Mobile) (Place of Employment)
Address (Optional): ___________________________________________________________________________________________
No & Street City/State Zip
Are you employed? Yes No Does employer allows telephone contact? Yes No
Place of Employment __________________________________________________________________________________________
Supervisor’s Name (in the event of an emergency):
Do you have children? Yes No How many? __________
List children’s ages: ___________________________________________________________________________________________
If you are in class and someone calls regarding your child/children, what school(s) do they attend or who is their care person?
STRENGTHS: WEAKNESSES:
HOBBIES: VOLUNTEER EXPERIENCES:
COMMUNITY ORGANIZATIONS: CAMPUS ORGANIZATIONS:
Do you plan to attend graduate school? Yes No If yes how soon ______________ (months/year)
If no, what are your career goals? ________________________________________________________________________________
____________________________________________________________________________________________________________
The above information is correct, and I will change any or all of the above information as changes take place to provide the Chair of
the Social Work Department and advisors of the necessary updated contact information and of my employment until I graduate.
Signature Date
Information Received by:
Signature Date
Revised 10/2013
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DEPARTMENT OF SOCIAL WORK BSW PROGRAM APPLICATION FOR (Darton State College)

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Completed 7 September 2020

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