Note: Transportation for field is required
A. Is your NASW Membership current ___Yes ___No
(Required to secure Professional Liability Insurance)
If no, have you applied? ___Yes ___No
B. Is your Professional Liability current? (required) ___Yes ___No
(attach copy of insurance first page)
If no, have you applied? ___Yes ___No
C. Do you plan to be employed doing your placement? ___Yes ___No
If yes, how many hours per week ____ (Please be advised that summer
block requires 38-40 hours of field)
D. Do you have a valid driver’s license? (attach copy of license) ___Yes ___ No
E. Do you have automobile insurance? ___Yes ___No
(attached a copy of your auto insurance)
Do you have a disability or medical condition which should be considered in arranging a placement
for you? If yes, please elaborate.
Have you ever been convicted or arrested of anything other than a minor traffic violation?
__ Yes __ No
(DUI is not considered minor). If yes, please explain (attach additional page, if necessary).
Please briefly describe your primary areas of interest for your concentration field placement:
Have you met all Program requirements to be eligible to enter SWK 680? Yes ___ No If
No, please explain.
Please identify three client groups you would like to have considered for your concentration Field
Practicum, in order of preference:
1.
2.
3.
