Fillable MSW App Form 091117 - Fillable Wichita State University

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MSW App Form 091117 - Fillable Wichita State University

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Name & ID#: ______________________________________________________________________________________________________________
Last First Middle (Preferred Name) Other Last Name(s) myWSU ID# (if available)
Present Address: ___________________________________________________________________________________________________________
Street and number City State Postal Code (Country)
Telephone: _____________________________________________ Email(s):________________________________________________________
Home Mobile
APPLICATION COMPLETION INFORMATION
• Complete the Application for Graduate Admission – https://applyweb.com/wichitas/index.ftl
o Attach to the WSU Graduate School Application:
Unofficial student transcript(s)
Personal Statement: Compose a self-reflective essay that demonstrates your interest and suitability for the MSW program and degree. To
ensure impartiality in evaluation, do not include your name or names of particular agencies in the title, body, or at the end of your essay.
Suggested length is 4 to 6 typewritten pages, double-spaced, 12-point font. Include the following:
Personal and professional values and/or beliefs that have led you to consider a graduate degree in social work
Your special interests for a career in social work
Experiences with people who are culturally, ethnically, or in other ways different from your own background
Personal experiences which contribute to your choice of a social work career
Professional and/or social service experiences which contribute to your choice of a social work career at the master’s level
This completed application form
o Three reference entered on WSU Graduate School Application (Advanced Standing applicants should have a licensed social worker for one of
the references.)
Professional reference
Academic reference (If you have been out of school for some time substitute another professional reference.)
Personal reference (not a relative or fellow student)
MSW PROGRAM TRACK
Indicate which program you are applying for:
Regular program – Undergraduate degree is not in social work or from a CSWE-accredited social work program (Fall semester admission only)
Advanced Standing Program – You have a BSW from a CSWE-accredited social work program (Summer term admission only)
Semester/term and year you plan to begin the program: Summer (Advanced Standing) Fall (Regular Program) 20 __________
Applicant must designate full-time or part-time program: Full time Part time
EDUCATION AND PROFESSIONAL TRAINING (Attach additional pages if needed.)
Undergraduate Education
Name & Location of College/University Dates Attended Major(/Minor) Degree & Date
_______________________________________________ ________________ _____________________________ ___________________
_______________________________________________ ________________ _____________________________ ___________________
_______________________________________________ ________________ _____________________________ ___________________
Cumulative Undergraduate GPA: _______________
Graduate & Professional Education and Training
Name & Location of College/University Dates Attended Major(/Minor) Degree & Date
_______________________________________________ ________________ _____________________________ ___________________
_______________________________________________ ________________ _____________________________ ___________________
Graduate GPA (if applicable): __________________
Field Practicum Experience in Social Work if applicable (agency, nature of work, nature of supervision, hours, etc.)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Distinctions or Election to Honor Societies
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
School of Social Work
MASTER OF SOCIAL WORK PROGRAM
Application for Admission
LIBERAL ARTS REQUIREMENT
Complete this section to demonstrate that you have met the liberal arts requirement. Attached transcript(s) will not substitute for completing this section.
Give course number, title, and year taken.
Humanities — 2 courses (History, philosophy, literature, fine arts, or similar disciplines)
(1) _____________________________________________________ (2) _____________________________________________________________
Social Sciences — 3 Courses (Psychology, sociology, political science, anthropology, economics, organizational theory, etc.)
(1) _____________________________________________________ (2) _____________________________________________________________
(3)
_____________________________________________________
Oral Communication — 1 Course (Speech, interpersonal communication, etc.)
(1) _____________________________________________________
Written Communication — 2 Courses (English, English composition, creative writing, technical writing, etc.)
(1) _____________________________________________________ (2) _____________________________________________________________
Human Biology — 1 Course (Anatomy, biological anthropology, etc.)
(1) _____________________________________________________
Analytical Skills — 1 Course (Mathematics, statistics, logic, computer science, etc.)
(1) _____________________________________________________
Human Diversity — 1 Course (Minority studies, women’s studies, human sexuality, special populations, anthropology, etc.)
(1) _____________________________________________________
EXPERIENCE (Attach additional pages if needed.)
List positions starting with most recent. Do not enter social work field placements. Work study or coop education related to social work can be included.
Social Service Experience – Paid Position
Employer: ___________________________________________________________ Length of Employment: _____________ Full time Part time
Duties: ___________________________________________________________________________________________________________________
Employer: ___________________________________________________________ Length of Employment: _____________
Full time Part time
Duties: ___________________________________________________________________________________________________________________
Social Service Experience – Volunteer Work
Agency: _____________________________________________________________ Length of Employment: _____________ Full time Part time
Duties: ___________________________________________________________________________________________________________________
Agency: _____________________________________________________________ Length of Employment: _____________
Full time Part time
Duties: ___________________________________________________________________________________________________________________
General Experience (other than Social Service)
Employer: ___________________________________________________________ Length of Employment: _____________ Full time Part time
Duties: ___________________________________________________________________________________________________________________
Employer: ___________________________________________________________ Length of Employment: _____________
Full time Part time
Duties: ___________________________________________________________________________________________________________________
CRIMINAL BACKGROUND CHECK
Have you ever been convicted of a felony or misdemeanor as an adult? Yes No
Has any governmental agency ever substantiated allegations made against you for physical, mental or emotional abuse or neglect, sexual abuse, or
exploitation of (1) a child, (2) a resident of an adult care home, medical care facility, psychiatric hospital or state institution for the mentally retarded, or
(3) an adult?
Yes No
If you answered yes to either of the above, please attach an explanation.
Answering “yes” does not automatically disqualify you for admission to the MSW program. However, depending on circumstances, it may affect your
ability to be placed in a field practicum which is necessary to complete the MSW program. Please contact the MSW Program Coordinator if you have
any questions.
I understand that prior convictions, diversions or pending charges may affect my ability to be placed in a field practicum which is necessary to complete
the MSW program. This means that while you may be admitted to the program, you may not be able to complete the degree if there is something in your
background that would prevent you from being placed in a field practicum. Many agencies require background checks. Some criminal charges may
affect your ability to be licensed in the State of Kansas.
I certify that the information on this completed application form is accurate and complete.
______________________________________________________________ _______________________________________________
Signature of applicant (Type name if submitting electronically.) Date
Notice of Nondiscrimination: Wichita State University does not discriminate in its programs and activities on the basis of race, religion, color, national origin, gender, age,
sexual orientation, marital status, political affiliation, status as a veteran, genetic information or disability. The following person has been designated to handle inquiries
regarding nondiscrimination policies: Director, Office of Equal Employment Opportunity, Wichita State University, 1845 Fairmount, Wichita KS 67260-0205; telephone (316)
978-6791.
(Rev 09/17)
Ethical Agreement
I, , certify that I have read and understand the NASW Code of Ethics
and I will abide by this code of ethics to the best of my ability. I aspire to learn more about social work’s values,
knowledge and practice skills throughout my student and professional years. I will seek professional growth
through interaction with faculty, colleagues and other assigned tasks in the Wichita State University School of
Social Work program. I understand that failure to demonstrate Social Work Ethics in my field practicum
placement may result in my removal from the program.
Signature of applicant (Type name if submitting electronically.) Date
Date
NOTE: The NASW Code of Ethics can be found on the NASW website at http://www.socialworkers.org/
.
Rev. 10/2011
MSW Manual Acknowledgement
I, , certify that I have been advised to read the Wichita State
University School of Social Work MSW Manual, located at
http://webs.wichita.edu/?u=socialwork&p=/msw/mswstudentmanual/
.
If admitted, I agree to fully read and follow the expectations outlined in that manual throughout the course of
study and during my field placement experience.
Signature of applicant (Type name if submitting electronically.) Date
06/2016
Computer Competency Statement
Students admitted to the School of Social Work are expected to demonstrate competency with the following
computer skills:
1. Word Processing (WORD or Word Perfect preferred – not Microsoft Works) with the following formatting
skills:
• Setting font size and type
• Setting margins
• Setting line spacing
• Creating headers and footers
• Inserting tables
• Italicizing
• Inserting page numbers – in a header
• Centering text; right and left justification
2. Sending and receiving email with attachments
3. Accessing the Internet
4. Students are expected to have familiarity with the following:
• Presentation program (PowerPoint)
• Spreadsheet (Excel)
Students not competent with the above computer skills must complete a computer class prior to
entering the Social Work Field Practicum Program.
I, , have been informed of the expected computer competency for the
Social Work program. I understand that it is my responsibility to demonstrate competency in the stated skills.
I understand that my grades may be significantly affected by poor application of the above
computer skills.
Signature of applicant (Type name if submitting electronically.) Date
10/2011
Liability Insurance Notification
I, , certify that it will be required for me to obtain Student Liability
Insurance as part of my practicum application process.
Signature of applicant (Type name if submitting electronically.) Date
NOTE: The NASW Social Work Student Professional Liability Insurance can be obtained by members of
NASW. To apply for membership online, go to www.socialworkers.org
. Application forms for the NASW
student liability insurance can be found at http://www.naswassurance.org/malpractice/student-liability-
individuals/ . There are other options for liability insurance, as well, through private providers or your own
insurance group. You are not required to purchase liability insurance through NASW.
06/2017
Office of University Relations • Wichita State University
MODEL’S RELEASE
I hereby grant Wichita State University and/or parties designated by Wichita State University
(including clients, purchasers, agencies and periodicals or other printed matter and their editors
the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works
from University-related photographs and/or audio recordings and/or video images of the
undersigned person. This grant includes, without limitation, the right to publish such images
and/or audio, with or without my name or with a fictitious name, in the University newspaper,
alumni magazine, and/or public relations / promotional materials, and any other marketing and
admissions publications, advertisements, fund-raising materials, and any other University-
related publication. The images and/or audio may appear in any of the wide variety of formats
and media now available to the University and that may be available in the future, including but
not limited to print, broadcast, videotape, CD-ROM, and electronic / online media.
I affirm that I am 18 years old or older:
Signature Date
Printed name
Witnessed by Date
If under 18 years old:
I am the parent or legal guardian of
I hereby approve the foregoing consent to Wichita State University’s use subject to terms
mentioned above. I affirm that I have legal right to issue consent.
Signature Date
Printed name
Witnessed by Date
LOCATION:
DESCRIPTION:
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MSW App Form 091117 - Fillable Wichita State University

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Completed 16 February 2020

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