Application to Enter the Field Practicumfor Next Academic Year 20______

OHIO UNIVERSITY

UNDERGRADUATE SOCIAL WORK PROGRAM

APPLICATION TO ENTER THE FIELD PRACTICUMFOR NEXT ACADEMIC YEAR 20______

STUDENT’S CAMPUS:

PLACE PICTURE BELOW: STUDENT’S PROFILE:

Name:
PID #:
Local Address:
Local Phone:
OU Email:
Summer Address:
Summer Phone:
Permanent Address:
Permanent Phone:

SPECIAL CIRCUMSTANCES:

(Briefly explain any factors which might have an effect on your field practicum; examples are lack of transportation, commuting from a considerable distance, physical challenges, employment schedule, or coursework in addition to social work practice courses):

SPECIAL SKILLS:

(Provide examples of special talents or expertise such as sports, arts and crafts, music, dance, theater, languages, computer skills, etc.):

AGENCY REQUIREMENTS:

(Evaluate if you meet the requirements of the specific agencies that you are considering for your practicum, particularly in relation to transportation and the suggested beneficial pre-placement experiences as outlined in the agency description in the Field Education Manual? If not, please explain):

ACADEMIC DATA:

Date of planned graduation:

Cumulative grade-point average (GPA):

RELEVANT COURSES:

(List courses in social sciences, other than social work, which you have completed or are in the process of completing; give title or description and not the course numbers, such as Deviant Behavior, Social Psychology, etc.):
(List courses that you have taken in other colleges of the university or workshops of particular significance to the social work profession, such as Interviewing (from the Communications College) or Human Sexuality (Biology) and provide the title and description):

CAREER GOALS:

(Write a brief description of your goals pertaining to your social work career):

VOLUNTEER EXPERIENCES I HAVE HAD:

Agency:
Number of hours served:
Roles or duties performed:
Agency:
Number of hours served:
Roles or duties performed:
Agency:
Number of hours served:
Roles or duties performed:

MY RELEVANT PAID EMPLOYMENT:

Employer:
Number of months or years:
Roles or duties performed:
Employer:
Number of months or years:
Roles or duties performed:
Employer:
Number of months or years:
Roles or duties performed:

ADDITIONAL LIFE EXPERIENCES:

(Please write a short statement below or attach a paragraph addressing any special life experiences or additional information that you believe will be helpful in relation to your career in social work or your field practicum assignment that have not been mentioned in any other portion of this application; examples are associate degree, living abroad, dorm activities, military experience, student organizations, community activities, etc.):

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