Fillable MSW 1 Field Application S17

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MSW 1 Field Application S17

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SWRK 280/281 Field Application
(First Year Field Placement)
Please complete this application and submit it to the Social Work Department Office. It provides basic information
necessary to begin planning your field placement. Application must be typed.
Title IV-E Applicant? YES NO
Last Name First Name
DOB
Student ID
Address Apt. #
City State
Zip
Preferred Phone
Type
Email Address
Applicant Gender Female Male Children: YES NO Ages:
Applicant Ethnicity Marital Status Spouse’s Occupation Spouse City of Employment
Name of Contact Relationship Home Phone Cell Phone
Address Apt. # (If applicable)
City State
Zip
Will you have use of a car during your field placement? YES NO
If you will not have use of a car, please describe how you plan to get to the field agency, visit clients, etc.
YES NO If yes, list the language(s):
If yes, answer with a (yes) or (no) to the reading, writing, and speaking questions.
Are you fluent in reading:
Writing:
Speaking:
THIS APPLICATION MUST BE TYPED
OPTIONAL
IN CASE OF EMERGENCY WHILE IN FIELD PLACEMENT CONTACT:
TRANSPORTATION FOR FIELD PLACEMENT INFORMATION
DO YOU HAVE KNOWLEDGE OF A LANGUAGE OTHER THAN ENGLISH?
MSWI Field Application
Summer 2017
Select One
Employment Information: If you will be employed during your internship, please provide information regarding your
place of employment, work schedule, and plans to accommodate work and internship.
PLEASE NOTE: If you are interested in applying to do your internship in your agency of employment, please review
the in agency guidelines on the DSWE website, then contact the Field Coordinator or Assistant Field Coordinator as
soon as possible at 278-3992 for further information.
Agency Dates Job Title Paid/Volunteer/Intern
1.
2.
3.
4.
5.
University/College
Major Date of Degree
1.
2.
3.
4.
5.
PLEASE NOTE: If there is additional information to be considered in planning your internship, please include it on a
separate page attached to this application.
I authorize the above material to be reviewed by field instructors and/or supervisors with whom I may be assigned.
Signature Date
PREVIOUS WORK EXPERIENCE & VOLUNTEER WORK (INCLUDE PRIOR INTERNSHIP)
MSWI Field Application
Summer 2017
Geographic Preference: Many of our placements are in communities throughout the San Joaquin Valley. Below are
listed the geographic areas utilized for field internships. List your preferences for at least five (5) areas. Use “1” for
most preferred, “2” for the next most preferred, etc. Please note that placements are NOT available in every location
every year. We cannot guarantee that you will receive a placement assignment in one of your preferred areas.
Dinuba/Reedley Northfork/Foothills
Fresno metropolitan Central Coast
(San Luis Obispo, Atascadero)
Madera Merced
Southwest Valley
(Hanford, Coalinga) Southeast Valley (Porterville/Exeter)
Visalia/Tulare
Age Group Interest: Please indicate your interest in working with the following groups. Use “1” for highest interest,
“2” for the next highest interest, etc. through “4”
Children
Adolescents
Adults (young to middle adult) Older adults
Areas of Practice Interests: Indicate at least four (4) of your field placement interests in rank order. Use “1” for
highest interest, “2” for the next highest interest, etc. Please note that placements related to every interest area are
not available in every geographic location.
Aging/Gerontology Adoptions
Public Child Welfare Education/Mentoring/Higher Education
Corrections/Criminal Justice Alcohol/Substance Abuse (AOD)
Health/Medical Social Work Community Organization/Outreach
Hospice Mental Health/Behavioral Health
Child/Adolescent Services School Mental Health
Other (identify):
GEOGRAPHIC LOCATIONS
MSWI Field Application
Summer 2017
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MSW 1 Field Application S17

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Completed 29 May 2020

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