CUA
The Catholic University of America
NationalCatholicSchool of Social Service
Office of Field Education
Washington, DC 20064
Phone 202-319-5457
FIELD PLACEMENT APPLICATION
for Undergraduate BSW Juniors
(please type)
Date ______Student ID # ______Date of Birth______
Name ______E-mail______
Local Address ______
Phone (cell) ______Phone (home) ______Phone (winter break)______
Insurance Coverage:
Are you covered by the CUA Student Health Plan? Yes No
If no, provide name and address of provider, & policy #:______
Personal information:
- Do you have a driver’s license? Yes No
- Will you have a car to get to and from field agency? Yes No
.If you will have a car, are you willing to use your car to transport clients? __ Yes __ No
(Our policy prohibits students from driving their own vehicles to transport agency clients unless they voluntarily elect to transport clients in their vehicles in order to be placed in a particular agency/kind of agency. If this will be a requirement, it should be discussed and agreed upon at the placement interview.)
- Do you speak another language? Yes No
If yes, do you wish to utilize this language in field agency, if possible? Yes No
If yes, name language and indicate level of proficiency: ______
Readiness for Social Work Internship
Please write an essay addressing the following questionson a separate page and submit it with your field application.
1)Describe your social work interests.
2)What population would you like to work with in your junior field placement? Why?
3)What skills or experience do you bring to your first social work internship?
4)What are your long term social work goals?
5) Describe the ways you will be of service to clients, the field agency, and the social work profession.
- List of agencies in which you are interested in interning in the Junior Year Field Placement:
- Please consult your Spring class schedule. Indicate all 4-8 hour blocks of time that you will be available to fulfill your 8 hours/week at field placement. Field hours will be considered during placement process. Field hours are done in one 8 hour day per week, or two 4 hour shifts per week. Weekly schedule will be approved by field instructor prior to start of your internship, and will be consistent for the duration of the semester.
Monday ______
Tuesday ______
Wednesday ______
Thursday ______
Friday ______
- If you have a documented disability for which you would like to request reasonable accommodations in your field agency, you must identify yourself to the CUA Office of Disability Support Services (DSS), (202-319-5211) and notify them that you will be applying for a field internship. Once your disability is verified and you have been approved for services through DSS, you must then speak with the Director of Field Education if you wish to request accommodations in your field placement. It will greatly assist the Director of Field Education in referring you to the most appropriate field placement to have knowledge about reasonable accommodations that have been determined by DSS for you before referring you for an interview.
- Please provide contact information for an individual whom we may call in the event of an emergency at your internship site. This person would only be contacted in the event of an emergency, e.g. medical emergency or accident.
Name: ______Relationship: ______
Phone: (cell): ______(work): ______(home): ______