Fillable MSWI. Field Application (California State University, Fresno)

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MSWI. Field Application (California State University, Fresno)

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California State University, Fresno
Department of Social Work Education
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.
THIS APPLICATION MUST BE TYPED
Are you concurrently applying for the Title IVE Program and SWRK 280/281?
Title IV-E Applicant
Last Name:
First Name
DOB
Student ID
Address Apt. # (If applicable)
City
State
Zip Code
Home Phone Work Phone
Cell Phone/Pager
Email Address
Optional:
Applicant
Gender:
Female
Male
Children:
YES
NO
Ages:
Applicant Ethnicity
Marital Status: Spouse’s Occupation: Spouse City of Employment:
IN CASE OF EMERGENCY WHILE IN FIELD PLACEMENT CONTACT:
Name of Contact:
Relationship
Home Phone
Cell Phone
Address
Apt. # (If applicable)
City
State
Zip Code
TRANSPORTATION FOR FIELD PLACEMENT INFORMATION:
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.
DO YOU HAVE KNOWLEDGE OF ANOTHER LANGUAGE?
YES
NO If yes, list the language(s):
Do you want a placement where you may use your language skill(s)? YES
NO
If yes, answer with a (yes) or (no) to the reading, writing, and speaking questions:
Are you fluent in reading: Writing: Speaking:
@mail.fresnostate.edu
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 contact the Field
Coordinator or Assistant Field Coordinator as soon as possible at 278-3992 for information on guidelines and application
procedures.
PREVIOUS WORK EXPERIENCE & VOLUNTEER WORK
Agency
1.
Dates
Job Title
Paid/Volunteer
2.
3.
4.
5.
UNDERGRADUATE & POST GRADUATE EDUCATION:
University/College
1.
Major
Date of Degree
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
Updated 12/16/2011
GEOGRAPHIC LOCATIONS
Geographic Preference: 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 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.
Bakersfield (far south valley) Dinuba/Reedley
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) Other 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.
Administration Adoptions
Aging/Gerontology Education/mentoring
Employment/Training/Public Welfare Alcohol/Substance Abuse
Abuse/Protection Services Community Organization/Outreach
Corrections/Criminal Justice Developmental and/or other disabilities
Domestic Violence Evaluation/Research
Health/Medical HIV/AIDS Services
Hospice Immigration/refugee services
L/G/B/T /Q Mental Health
Public Policy Schools K-12 (second year only)
Other (identify)
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MSWI. Field Application (California State University, Fresno)

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Completed 16 July 2020

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