APPENDIX D:
GRADUATE SOCIAL WORK PROGRAM
ALABAMA A&M UNIVERSITY
FIELD PRACTICUM APPLICATION
FOUNDATION (First Year) STUDENTS
(SWK 581) * Must be submitted by the 1
st
of September, prior to the planned field practicum in the Spring
semester , or February 1
st
for Summer Block or Fall semester. This application must be completed in its
entirety, inclusive of all required signatures. (Please type or print legibly in black or blue ink). If the 1
st
falls on a weekend, the application is due on the next business day.
Date:
Name:
Mailing Address:
City: State: Zip Code:
A# Number :
Telephone Numbers:
Home Work:
Cell Email Address:
College(s) Attended:
Degree & Year: Major:
Program Plan: Campus Location: Placement Plan :
___Full Time (60 hrs.) ___ Alabama A&M Univeristy ____ Fall
___Part Time (3 year) ____Spring
___Part Time (4 year) ___ Lawson State Community College ____Summer
___Weekend Program
Note: Transportation for field is required
A. Do you have a valid drivers license? Yes No
(attach copy)
B. Do you have Auto Insurance? Yes No
(attach copy of Insurance card)
C. Do you have transportation? _______Yes _______No
D. Are you a member of NASW? Yes No
(Required to secure Professional Liability Insurance)
If no, have you applied for Membership _______Yes _______No
E. Do you have Professional Liability Coverage? Yes No
(Required for placement)
If no, have you applied for Membership Yes No
