Fillable Undergraduate Field Application 11.22.16

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Undergraduate Field Application 11.22.16

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SWRK 181/182 Undergraduate Field Application
Before scheduling your “Field Placement Interview” appointment, you must complete the steps below:
1.
Meet with your advisor; Take the advisor form, a copy of your current DPR report, & the “Senior Plan” form to be reviewed.
Note: The advising form must be signed by you and your advisor.
2.
Complete this field application.
3.
Bring the completed field application, signed advisor form, and current DPR report to the DSWE Office (PHS 128). At this time, schedule an
appointment for a “Field Placement Interview”. NOTE:
NO APPOINTMENTS will be made WITHOUT HAVING ALL THE DOCUMENTS
REQUIRED.
APPLICATION MUST BE TYPED
Do you plan to apply for Title IV-E?
YES NO
UNSURE
Last Name First Name
DOB
Student ID
Address
Apt #
City State
Zip Code
Preferred Phone #
Type
Fresno State Email Address
Gender: Male Female
Do you have Children?
YES NO
Ages of Children
Student Ethnicity Spouse’s Occupation Spouse City of Employment
Name of Contact
Relationship
Home Phone Cell Phone
Address
Apt #
City State
Zip Code
Do you speak another Language?
YES NO
If yes, please list the language(s):
Do you want a placement where you may use your language skill(s)?
YES
NO
If yes, are you fluent in any of the three skills listed:
Reading Writing
Speaking
APPLICATION INFORMATION
OPTIONAL
IN CASE OF EMERGENCY WHILE IN FIELD PLACEMENT CONTACT
Choose One
Will you have use of a car during your field placement?
YES
NO
If yes, are there any qualifications on use? Please explain below.
If no, please explain below how you plan to get to the field agency, visit clients, etc.
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.
I plan to work after completion of my BA Degree
Continue immediately into graduate study in the area of
Work first, and then continue graduate study in the area of
Other (please explain):
Agency Name
Dates
Job Title Paid/Volunteer
1.
2.
3.
4.
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
to.
Signature Date
PREVIOUS WORK EXPERIENCE, INTERNSHIP & VOLUNTEER WORK
CURRENT EMPLOYMENT INFORMATION
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 preferences for at least
three (3) 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
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
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.
Adult Services Child Welfare
Aging/Gerontology
Youth Service
Education/Mentoring
Employment/Training/Public Welfare
Alcohol/Substance Abuse Community Organization/Outreach
Corrections/Criminal Justice
Developmental and/or other disabilities
Domestic Violence Mental Health
Health/Medical
Public Schools K-12
Immigration/Refugee Services
Public Policy
University Services
Other (identify):
Updated Fall 2016
GEOGRAPHIC LOCATIONS
AGE GROUP INTEREST
AREAS OF PRACTICE INTERESTS
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Undergraduate Field Application 11.22.16

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Completed 29 May 2020

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