California State University, Long Beach
School of Social Work
Pupil Personnel Services Credential Program
APPLICATION FOR 2017 - 2018
Name: Student ID#:
E-mail:
Program Model: ___2 Year ___3 Year ___Advanced Standing
Home Phone: Cell Phone:
Ethnicity: Language Fluency other than English:
Current Field Placement:
Agency Name
Semester/year when you successfully completed SW 665:
OR
Semester/year when you plan to enroll in SW 665:
I have read the following and fully understand (please initial each):
___ all of the requirements (as stated in the Required Field Placement Activities form and the General Requirements document) for the PPS Credential Program.
___ the School of Social Work must receive notification that I have received clearance from the Commission on Teacher Credentialing (CTC) before I will be accepted into the program.
___ I must open a file with CSULB’s Credential Center on campus and take all 3 sections of the CBEST exam OR provide proof that you have successfully completed the basic skills requirement http://www.ctc.ca.gov/credentials/leaflets/cl667.pdf before I can begin my field placement and that my field placement will be delayed until these are completed.
___ I must complete all of the clearances and medical procedures required by the school in which I have been placed before I can begin in my internship.
___ I must successfully complete each of the required elements of the program and receive the recommendation from my PPSC School Site Field Instructor in order for the School of Social work to recommend me for the credential.
__________________________________ _ ______________________
Signature Date
Personal Statement for PPSC Application: 2017–2018
The submission of a one-page personal statement must accompany the application by the announced deadline. This statement includes a discussion of the following:
· Reasons the student wants to be a school social worker;
· The attributes the students have that will assist them in preparing to be a school social worker (including prior experience); and
· How they see using this credential after graduation.
THIS PROGRAM IS FOR CURRENTLY ENROLLED
CSULB SCHOOL OF SOCIAL WORK STUDENTS ONLY.
THE APPLICATION & CTC CLEARANCE MUST BE SUBMITTED HARD COPY ONLY TO
SAANA POLK, MSW, PPSC BY 5:00PM: MONDAY, JANUARY 30, 2017
*STUDENTS INTERESTED IN BOTH THE PPSC AND UCCF PROGRAMS FOR THEIR SECOND-YEAR FIELD PLACEMENT MUST SELECT ONE OF THE PROGRAMS AS THEY SUBMIT THEIR FIELD APPLICATION.