Fillable MSW Campus Student Information Form Revised Aug 2021 (Dalhousie University)

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MSW Campus Student Information Form Revised Aug 2021 (Dalhousie University)

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The MSW Campus Student Information Form Revised Aug 2021 (Dalhousie University) form is 3 pages long and contains:

  • 1 signature
  • 15 check-boxes
  • 30 other fields

Country of origin: CANADA
File type: PDF

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1
School of Social Work
1459 LeMarchant St., Suite 3201
P.O. Box 15000, Halifax, Nova Scotia
Canada B3H 4R2
Phone (902) 494-1187
Fax (902) 494-6709
MSW STUDENT INFORMATION FORM CAMPUS
Name of Student:
Student Number:
Preferred Name: Pronouns:
Dalhousie Email Address:
Current Address:
Postal Code:
Telephone Numbers: (H) (W) (C)
Placements will sometimes specifically request students from certain groups who may share lived
experience, heritage, language, etc… with the clients/communities they serve etc. We invite you to use
this space to list any identities that you feel comfortable disclosing that could help with placement
matching:
Please check when you plan to do your Field placement:
January to June (2 days/week for 28 weeks) (Part-time)
Full-time Placement (13 weeks) from to
I have a BSW from
Date Completed:
2
Agencies you are interested in: (Please note that it may not always be possible to secure a placement in your
preferred location). Please specify priority.
1.
2.
3.
4.
Specify Areas of Practice Interest (i.e. Physical Medicine, Policy Development, Counselling, Community
Development, Mental Health) in order of priority.
1.
2.
3.
4.
EMERGENCY CONTACT:
Please indicate who we should contact in the event of an emergency.
Name Phone#/Email
Relationship to You
3
Student Signature Date
Please check this box to indicate electronic signature:
Please return form to:
Field Education Assistant
sswfield@dal.ca
Note: Completion of this form is required as part of the Student Submission Package.
(DIS)ABILITY SUPPORT FOR FIELDWORK
There is support for students who need accommodations for fieldwork due to a (dis)Ability. If you have a
(dis)Ability and might require accommodations within fieldwork please register at the Mark A. Hill
Access and Advising Centre located in the Killam Library Building (see link below). The School’s
Accommodation Officer/Associate Director is also available to discuss your accommodation needs
particularly if those needs extend beyond the services of the Mark A. Hill Centre. It is advisable to register
even if you are not certain you will need accommodations so we are prepared to support you if needed.
http://www.dal.ca/campus_life/academic-support/accessibility.html
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MSW Campus Student Information Form Revised Aug 2021 (Dalhousie University)

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Completed 13 September 2021

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