Field Practicum Application – MUST BE TYPED

Applicant Information

Full Name:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
CellPhone: / ()- / Work Phone: / () -
* UMKC Email: / Personal Email:
Foundation= entering 1st field placement
Concentration= entering 2nd field placement
BSW Adv=accepted into accelerated program / Upcoming school year, I will be in my… (check one)
Foundation Practicum: 1st placement
ConcentrationPracticum: 2nd Placement
BSW Advanced Standing: Only Placement
BSW Degree awarded from:
* Please submit a copy of your last BSW field contract and evaluation with this application.
Date of Application: / //

Important Information

Application / Email completed application to .
Once your complete application is received and reviewed, you will be contacted to schedule an appointment with the Field Office.
No appointments can be scheduled with the Field Office until the completed application is received!
Malpractice Insurance / Thecost of malpractice insurance is covered by course fees.
Placement / Field Placements are competitive. Early application and interview helps ensure you have a choice of field practicums.
Correspondence / All correspondence will be sent to your campus (UMKC) email address. You must check this address frequently to be sure you are receiving important field practicum information.

Employment Information and Relevant Experience

Place of Employment: / Dates of Employment: to
Current Job Title:
Experience in Social Work/Helping Services:
Geographic Preferences for Placement/Limits to Transportation:
Though there is no guarantee that your placement will be within your geographical preference, please be aware that the Field office does take this into consideration.
Xxxxx
Languages Spoken:

Self-Profile

Please thoughtfully consider your responses in this section.
Describe your experience in living and/or working with diverse populations:
Describe how your personal strengths or qualities will contribute to your role as a professional social worker:
Do you require any special accommodations at your placement? Explain:
Describe the type of structure you need in order to work effectively:
Rate your level of proficiency in the following areas.
Place an X in the appropriate box: (1=excellent, 2=good, 3=fair, 4=poor)
Placement Tasks/Environments / 1 / 2 / 3 / 4
Working in a fast-paced environment
Working with limited direct supervision/instruction
Organizational skills
General office tasks (computer, fax, documentation, etc.)
Community/client engagement
Practicum Settings and Career Goals
Utilize the information you completed in the self-profile as a guide in completing the following. Indicate your 1st, 2nd, and 3rd choices only in order of preference:
Aging/Gerontology / Medical Social Work / Administrative
Substance Abuse & Addictions / Behavioral (Mental) Health / Community/Family Violence
Child Welfare / School Social Work / Immigration/Refugee
Homeless/Community Housing / Community Advocacy / Policy / Incarceration Re-Entry
Hospice / Youth Services / Poverty
Developmental Disabilities / Veterans / Other:
Social Work Career Goals: Indicate social work experiences you wish to explore, skills you wish to acquire and career directions you are considering:
Why did you select the three (3) preferences above? (Please provide reasoning for each)
1.
2.
3.
Special Concerns and Release of Information
Special Relationship(s)
Do you have a personal relationship/conflict of interest with anyone at your requested practicum agencies?
NO YES
If yes, describe the nature of that relationship:
Special Concerns
An increasing number of these agencies are requiring practicum students to submit to background checks that can include, but are not limited to: criminal background checks, fingerprinting, and drug testing. The screenings are most often arranged directly between the students and the interviewing agencies. The School of Social Work does not pay for any fees associated with the screenings. While past experiences do not necessarily limit an applicant’s acceptance into the programs, some experiences may severely limit placement options. Please note below any of your life experience of which you think the Director of Field Education should be aware in order to most successfully arrange your practicum placement(all legal concerns beyond a misdemeanor should be included).
Please list any special concerns you may have:
Release of Information
I grant permission to the Field Practicum Office of the University of Missouri-Kansas City School Work to release information from this Practicum Application for the purpose of arranging my practicum placement. This release extends to several agencies when necessary for confirmation of a mutually agreeable placement.
Student Signature:______Date: ______
Work–Site Placement
All worksite placements must be approved and require an on-site visit prior to the beginning of the semester.
If you would like the Field Office to consider using your place of employment for your practicum site complete the Employer Agency Field Practicum Application, found on the last page of this application.
Your practicum will not continue should your employment voluntarily or involuntarily terminate.
Work-Site Field Practicum placements must meet the following criteria:
1) Student must answer to a different supervisor than their current employment supervisor
2) Employment work hours and practicum hours must be different
3) Practicum must involve work within a different population, department, role, etc. than current employment.
4) The agency must support the student's obligations for academic coursework and assignments.

UMKC School of Social Work - WORK-SITE APPLICATION

In order to request a Work-Site Field Practicum placement, this worksheet must be completed by the student, their current employment supervisor and the proposed Field Instructor.

Not all applications are approved.

Student: ______

Agency: ______

Job Title: ______Length of Employment: ______

Identify how current employment differs from proposed Practicum experience:

Supervision
Current Employment Supervisor / Proposed Field Instructor (MSW)
Name / Title :
Phone:
Email: / Name / Title :
Phone:
Email:
Work Hours (practicum hours must be different from your current work hours)
Current / ProposedPracticum
Major Duties, Activities and/or Tasks(practicum duties, activities, and/or tasks must be different from your current work duties, activities, and/or tasks)
Current / ProposedPracticum

Signatures

______

Student Date

______

Current Employment Supervisor Date

______

Proposed Field Instructor Date

Approved: ______

Office of Field Education Date

Field Education Application (Rev 1/2018) 1