Application for Second YearMSW Social Work Field Placement
Department of Social Work
The University of North Carolina at Charlotte
9201 University City Blvd.
Charlotte, NC 28223
OFFICE USEPLACEMENT REQUESTED FOR:2015-2016
DATE RECEIVED: ______Academic Year
Field of Practice Emphasis:
Instructions:
This application will be used to recommend a field agency that is appropriate for your development of social work practice knowledge, skills, and values at an Advanced Level. This application and your updated resume will also be forwarded to your prospective agency and used as a screening tool for the agency to decide on interviews. In addition, a personal interview with the Director of Field Education will be required in person, Skype, or telephone to assist with the process of selection.
It is extremely important that you complete each section of this form and submit by the deadlines noted. The form should be typed and submitted to the Directorof Field Education electronically. Please return this application to: Ms. Susan Marchetti at
Answers to questions that are narrative in nature should be typed, are recommended to be at least one (1) page, but should not exceed two (2) pages per question.
Please return:
- One (1) copy of the application and all attachments; and
- One (1) copy of your current resume; and
- References if required;
Application due date for 2015-2016 academic year is no later than January 9, 2015 and may be earlier if required by a specific Agency.
1. Name: ______
2. Birthdate: ______
3. Home Address: ______
street or dorm
______
______
city state zip
Phone: (home)______
Phone: (work)______
Phone: (cell) ______
Email: ______
4.Temporary Address: ______
______
______
Dates available at this address: ______
Phone : ______
Comments: ______
______
5.College and University Education:
Institution Dates of Enrollment
______
______
______
6. Overall GPA (undergraduate) ______
7. Overall Grade Point Average (graduate school)
8. Field Evaluation Grade
9. All students must arrange their own transportation to field agencies. Will you have a
car available for transportation? ______yes ______no
If no, how will you arrange for transportation? ______
10. Many agencies require a criminal background check and/or a current drug screen as part of the placement process. Have you ever been convicted of any felony? Yes No
If yes, please specify______
______.
11. Do you anticipate being employed part-time during the field placement?
Yes______No______
If yes, how many hours per week do you anticipate working? ______
If yes, write a brief description of how you plan to balance the requirements of field
Placement and course work with the requirements of your paid work?
12. What do you expect from this advanced level internship? Please list three specific populations that you would like to work with and state your reasons for choosing these specific populations
13. What strengths and skills do you have as a student that you would like to highlight for your
prospective agency?
14. Please describe how you have grown as a professional as a result of your first year
placement.
15. What do you hope to accomplish as a social worker in 5 years and 10 years?
Please note that all MSWstudents will be covered under the University Professional Liability Insurance during the field placement.
I have completed this application to the best of my knowledge. I give permission for a copy of this application to be shared with the field agencies relating to field placement arrangements.
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DateSignature
1
2015-2016 AY-Advanced Year