UNIVERSITY AT ALBANY
SCHOOL OF SOCIAL WELFARE
APPLICATION FOR 2nd Field PLACEMENT – 2017
INSTRUCTIONS: Please complete and return this application along with:
1copy of an up-to-date RESUME (including 1st field)
your LETTER OF INTENT form
NAME:
LOCAL ADDRESS, PHONE NUMBER and EMAIL:
( ) Email:SUMMER ADDRESS AND PHONE NUMBER (IF DIFFERENT FROM ABOVE)
( )WHERE WAS (IS) YOUR 1stFIELD PLACEMENT?
Agency Name:Field Instructor’s Name:
Year Completed:
WHICH MSW ADVANCED CONCENTRATION HAVE YOU CHOSEN?
☐ Clinical Practice☐ M.A.C.R.O. Practice
For Office Use Only
COs: LIC/CAR:AGENCY ASSIGNED:
PROG/UNIT:
INSTRUCTOR:
COMMENTS:
FIELD PRACTICUM APPLICATION 2nd Field Placement
PLEASE CHECK THE POPULATION OR PRACTICE AREAS THAT INTEREST YOU MOST.
CLINICAL PRACTICEM.A.C.R.O. PRACTICE
☐ Aging/ Gerontology ☐EAP (Employee Assistance Program)
☐ Mental Health ☐ Staff Training
☐Health/Hospital ☐Management Information System (MIS)
☐ Chemical Abuse☐Community Organization
☐Schools☐Human Resource Management
☐ Children, Adolescents and Families☐ Program Development
☐ Disabilities☐Program Evaluation
☐ Corrections/Criminal Justice☐Research
☐Homeless☐Grant Writing
☐Domestic Violence☐Legislative Lobbying
☐ Rehabilitation☐Outreach
☐Grief and Loss☐Advocacy
☐LGBTQ☐Other, Please explain below
☐ Other, Please explain below
IDENTIFY/DESCRIBE THE AREAS OF COMPETENCE THAT YOU WOULD LIKE TO DEVELOP IN YOUR ADVANCED CONCENTRATION FIELD PLACEMENT.
FIELD PRACTICUM APPLICATION 2nd Field Placement
PLEASE DESCRIBE YOUR PREVIOUS EXPERIENCE WITH FIELD INSTRUCTION/ SUPERVISION (i.e. STYLE, PROS/CONS) AND YOUR APPROACH TO LEARNING AND SUPERVISION.
Do you speak a language other than English? ☐ NO ☐YES Click here to enter text.
Disabilities:
Reasonable accommodations will be provided for students with a documented disability. Any disability that requires an accommodation in field requires a formal request for accommodation be made to the University at Albany’s Disabilities Resource Center in Campus Center-137 or (518) 442-5490 as soon as possible. Thereafter, the Field Office will work with students and field agencies in an effort to provide such accommodations. Below, please indicate if you will be requesting an accommodation in field as a result of reported disability that has been filed with the University at Albany’s Disabilities Resource Center. If not indicated, please write “N/A”.
FIELD PRACTICUM APPLICATION 2nd Field Placement
ANYTHING ELSE THAT YOU WOULD LIKE CONSIDERED IN DEVELOPING YOUR PLACEMENT, IF POSSIBLE?
Information related to placement Location:
(If your answer is “no” to any of the following questions, please understand that your options may be limited)
Do you have a current driver’s license? ☐ YES ☐ NO
Do you have a car available to travel to and from field? ☐ YES ☐ NO
Some agencies expect students to have a car available for
travelrelated to the placement (not client transport). ☐ YES ☐ NO
NOTE: The School’s policy states that you may be placed in an agency that is located within a 100 mile radius of Albany or your home community. However, every effort will be made to accommodate preferences where possible.
PLEASE INDICATE IN WHICH COUNTIES YOU WOULD PREFER TO BE PLACED:
North Country Central NY Vermont
☐Clinton☐ Broome☐ Addison
☐ Essex☐ Chenango☐ Rutland
☐ Warren☐ Cortland☐ Bennington
☐ Washington☐ Delaware
☐ Hamilton☐ Oneida
☐ St. Lawrence☐ Tioga
☐ Franklin☐ Tompkins
☐ Otsego
☐ Onondaga
Capital District Southern NY Massachusetts
☐ Albany☐ Dutchess☐ Berkshire
☐ Columbia☐ Ulster☐ Hampshire
☐ Fulton☐ Orange
☐ Montgomery☐ Putnam Connecticut
☐ Rensselaer☐ Sullivan☐
☐ Saratoga
☐ Schenectady
☐ Greene
☐ Schoharie
FIELD PRACTICUM APPLICATION 2nd Field Placement
PLEASE LIST 3 AGENCIES OR TYPES OF PRACTICE SETTINGS (IN ORDER OF PREFERENCE) THAT YOU ARE INTERESTED IN AS EXAMPLES FOR YOUR 2ND FIELD PLACEMENT.
I have completed and attached my Letter of Intent form and a copy of my updated resume including my 1st field placement.
Student NameDate
STUDENT ID:______Page 1