Fillable MSW Second Year Field Application F17

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MSW Second Year Field Application F17

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SWRK 282/283 Field Application
(2nd 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.
Tittle IV-E PPS
Last Name First Name
DOB
Student ID
Gender Fenale Male Do you have children? Y N Ages of children:
Student 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 Code
DO YOU HAVE KNOWLEDGE OF ANOTHER LANGUAGE? YES NO
If yes, list the language(s)
Are you fluent in:
Writing Speaking
Reading
THIS APPLICATION MUST BE TYPED
Address
Apt #
City
State
Zip Code
Preferred Phone
Type
Email Address
IN CASE OF EMERGENCY DURING FIELD PLACEMENT CONTACT:
Fall 2017
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.
Note: If you are interested in applying to do your internship in your agency of employment, please contact the Field Coordinator or
Assistant Field Coordinator as soon as possible at 278-3992 for information on guidelines & application procedures.
Agency Dates
Job Title Paid/Volunteer
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
EMPLOYMENT INFORMATION
PREVIOUS WORK EXPERIENCE, INTERNSHIP & VOLUNTEER WORK (Include first year MSW Internship)
UNDERGRADUATE & POST GRADUATE EDUCATION
Fall 2017
Choose One
Choose One
Choose One
Choose One
Choose One
Many of our placements are in communities throughout the San Joaquin Valley. Below are listed the geographic areas in
which we plan for field internships. List your preference for at least five (5) locations. Use “1” for the most preferred, “2” for the
next most preferred, etc. Please note that placements are NOT available in every location every year. Students are not
guaranteed to receive a placement in the area of their choice.
Atascadero
Madera
Bakersfield
Merced
Dinuba/Reedley
Porterville
Fresno & Vicinity Visalia/Tulare
Hanford
Other
Central Coast (San Luis Obispo , Arroyo Grande)
Indicate below your field placement interests by ranking at least four (4) preferred areas from those listed; including any listed by
you in the “other” category. Use “1” for the most preferred, “2” for the next preferred, etc. Please note that placements related to
all interest areas are not available in every geographical location.
Administration
Health/Medical
Adoptions
Adult Ed/Employment Training
Hospice Aging/Gerontology Alcohol/Substance Abuse
Mental Health, Children Child/Adolescent Services
Mental Health, Adults Child Welfare Services
Policy Planning Community Organization/Outreach
Public Schools (PPS Program, Second Year Only) Corrections
University Student Services Developmentally Disabled
Disability
Domestic Violence
Other
GEOGRAPHIC LOCATIONS
AREA OF PRACTICE INTERESTS
Fall 2017
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MSW Second Year Field Application F17

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Completed 29 May 2020

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