UPPApplication1

CHILDWELFAREUNIVERSITY PARTNERSHIPPROGRAMAPPLICATION

TheUniversityofAkron,SchoolofSocialWork

ReturnAppficationandTwoReferenceLettersto:

BeckyThomas,MSW,LISW-S,ACSW,Ph.D.Candidate,CWUPPCampusCoordinatorTheUniversityofAkron,SchoolofSocialWork

415DPolsky Building

Akron,Ohio44325-8001

CHILDWELFARE UNIVERSITY PARTNERSHIPPROGRAM APPLICATION

UniversityStudentID
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StudentName
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PermanentAddress··
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City
I •
.
State,ZipCode
. / .
. / PermanentPhones
Day / .
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Cell
LocalPhones.
Day
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'.Email / . / • / .· / ·.
' / University
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Other
.. / . / .
CurrentYearinSchool
.·.
I / MSW,Degree
. / .
. / •Yes
•No / IfMSW,dateofgraduationfromUndergraduateDegree
CurrentGPA / . / Overall / . / Social Work

Optional-ForStatisticalPurposesOnly

ApplicationDeadline
. . / DateApplicationReceived
StudentAdm.ittedtoUPP / "Yes
•No
NumberofYearsinUPP
PriortoCurrentInvolvement

UniversityPartnership/TitleIV-EChildWelfareTraining ProgramFieldAgencyPreferenceForm

Ifacceptedintothisprogram,wewilldoourbesttomatchyouwithyourpreferredfieldagency,accordingtoyourinterestsanddistancefromyourresidenceduringtheacademicyear.Below areseveralOhioChildrenServicesBoardsthatofferfieldplacements.Whilemanystudentsprefertostaywithin SummitCounty,thisagencymaynotbeabletoprovideplacementstoalloftheUPPstudents.Tl1us,itisimportanttorateatleast3-5agencies.Pleaseindicateyourlevelofinterestineachoftl1eagencies,ratingitfrom1=Mostinterestto·1O=Leastinterest

AshlandCoCSB--StarkCoCSB---TrumbullCoCSB---

GeaugaCoCSB_ / SummitCoCSB_ / WayneCoCSB_
MedinaCoCSB_ / OtherCountyCSB_

*Thispageofyourapplicationwillnotbesharedwithprospectivefieldagencies.

FieldPlacement'ToBeCompletedByCoordinator
•·...
FieldAgency
.· / FieldInstructor
Address
City ..
. / State / County / ZipCode
.
Phone
. / Cell
Fax / Other
.
EducationalHistory
.
CollegeAttended
.. / DatesofAttendance / DegreeReceived / DateofGraduation
PreviousFieldExperience
Agency / DatesofExperience / Duties / Supervisor
CurrentandPreviousChildWelfareExperience
....
Agency.. / DatesofExperience
. / Duties / Supervisor

IDoYouReceiveFinancial Aid?

tiYes

tiNo

AcademicAwards,Scholarships,Publications,Presentations
Tlt!eofAcademic
Awards, Scholarships,Publications,Presentations / DescriptionofAcademicAwards,Scholarships,Publications,
Presentations / Date
CurrentEmployment History
Placeof
Employment / Jobtitle / Duties / DatesofEmployment / WorkDays
Hours
HistoryofEmploymentwith PCSA / tt Yes
ti No

*AttachResumetoApplication

Volunteer/CommunityServiceExperienceDuringthePastTwoYears
......
Agency · / DatesofService
. / Duties / . / . / AgencyAddress / . / Supervisor / Phone
. / . / References / .
Name / Agency / Address / . / . / Phone

•seeAttachedReferenceForms

.
Transportation
Doyouhaveareliablecarwithinsurance?
... .·.. / •Yes
•No
AutomobileInsuranceCompany
.
Areyou.willingtotransportclientsaspartoffield placement? / •Yes
•No
Driver'sLicenseNumber
..
Automobile
. / Make
. / LicenseNumber
.

TheUniversityofAkron

ChildWelfareUniversityPartnershipProgramFieldPlacementDisclosureForm

FieldPlacementhasasitspurposetheopportunityforstudentstointegrateclassroom theorywithclientsystemspracticeandtodevelopprofessionalidentityandskills.

Practicetakesplaceinabroadrangeofsocialservicesettings.Themarketofavailableplacementpositionsislimited,and agenciesarehighlyselectiveofthestudentstheyaccept.Someagenciesquireandexecutebackgroundchecksformisconduct,suchasfelonyconvictionsordocumentedviolationsof thenationalAssociationofSocialWorkerscodeofEthics.

TheUniversityofAkron,SchoolofSocialWorkrequireseachfieldapplicanttosignthisdisclosureform.This formallowstheSchooltoinformastudent'sprospectivefieldagenciesofcurrentorpastfeloniousconvictions;orotherdisciplinaryproceduresorothermisconductinviolationsofinstitutionswheretheindividualmayhaveattended;orothermisconductinviolationoftheNASWCodeofEthics.Agenciesneedthisinformationinordertoacceptyouasastudent.

PleasesignthisformandsubmititwithyourChildWelfareUniversityPartnershipProgramFieldApplication.Noapplicationwillbeprocessedwithoutthis form.

IherebygrantpermissionforTheUniversityofAkron,SchoolofSocial\Nork'Child WelfareUniversityPartnershipProgramtonotifyanyagencytowhichIapplyasafieldstudentofmycurrentorpastdocumentedfelonyconviction,criminalmisbehavior,orothermisconductinviolationoftileNAS\NCodeofEthics.IfurtherattestthatIhavediscussedwithtileofficialsofTheUniversityofAkronChildWelfareUniversityPartnershipProgramanycurrentand/orpreviouscriminalbackgroundinformation,whichisinclusiveofmovingviolations,misdemeanors,andfelonychargesandconvictions.

PrintName:------

Signature:_Date:------

UniversityPartnership/TitleIV-EChildWelfareTrainingProgramFieldCaseVignette

Counselor,Social1f(1rker;Wnrriage

andFnmi(}'TherapistBoard

loW!Et!lz<»dSul1•1075Co-.Ollio 431ll'.-'9l

CBTMINAl RECORQSCHECKBEOUIREQFORINITIAL!ICENSlJRE

Section4757.101oftheOhioRevisedCoderequiresallIndividualsapp/yirllJforaliceMeissuedbytheCSWMFfBoard(Board)tosubmitfinge1p1inl:!iforacriminalrecordscheckcompletedbytheOhioBureauofCriminalIdentiflcationandInvestigatioo(BCI)and!heFederal Bureauofnves!lgiltioo

(Fill).Thisappffatoapplicanl;J;forPC,PCC,CT,15W,USW,SWA,5WT,MFf,MFfandallTEMPs.

ApplicantsresidinginOhioarerequiredtoutilize'Webelied<',Ohfo'selectronicfinge11J1i11tsystem,toelect:rooiaillysubmittheirfingerprin!sroBC!.TheBoardwilttypicallyreceivethere5Ultllof•oimlralrecordsche:ksubmittedvia"Webcheck''wilhin7to10businessdays.Inaddiliootothe$22OC!feeand$24FBIfee,!hee!ed:roolcfinglEptlntiilgcom!lilnYli:!900C'fwillchargeitsownfeetopmcessthe

fingerprints.

Sincet'ielawrequiresapplicanl:llforlic"""-•retosubmitacriminalrecordschedccompletedbybothOCIandFBI,you usetl"Jeseivlces>fa'Webehed:"vendorthatpa1tkipateslntha"NationalWebChe:k.nThe Sheriffsoffice;:;in tOhiocoun!iapa1tldpateintha"Nal.iooalWebCheck." Alistofo!her'We!Jdieck"veOOooJ;InOhio,arrangedbycounty,isavllilableonlineat:

Whenlocatinganelectronicfingerprintingsiteonthiswebpage,pleasenotethatyou

.wll:i1usetheservicesofavendorthatbas(llCTfB )listedafterthevendor'sname.Onlythereentitiespartkipatein"NationalWe!JCheck."The8-0arddoesootendorseorrecommern:iany·spe:iflcelectronicfingerprintingcompany/age>cy.

Stepsfor"\VebCheck"

1.Identifya"WebCheck"vendorthatpaitidpatesinthe"NatiooillWel:JCheck.n

2.Submityoorfeedirectlytothe''Webelieck"vendor.DONOTSENDYOURfINGERPRINTSORFEETOTHEBOARD.

3.Requestthatthecriminalrecordshe<:kre::ulofromOO!htheBC!andFillbesentdirectlyto:

CooMelor,Social Wa<kerMarriageandfamilyTherapistBoard

SOWestBroad Street,Suite1075.------,

Columbus,Ohio 43215-5919ResultsIn115tbemailedfromBCI!oCS\\'MFTBD

4.Listtl·wereasoofor"!)erp1intingas:•Requiredforlicensurepet·ORC4757.lOl.andVolunteerfor

Children'sArt"

5.wntedea1!yinbfad:ink,asunreadable-cardswillberejected.Doootaltertt.ecardorboxes.

Instn1ctionsfgrlndiyidualzResjdirwOut:zidepfOhio