CALIFORNIA STATE UNIVERSITY, CHICO

SCHOOL OF SOCIAL WORK

TITLE IV-E CHILD WELFARE TRAINING PROGRAM

AFFIRMATION FORM

Please complete this affirmation form by typing into it or writing with black ink, and include it in your application packet. Incomplete application packets will not be included in the screening process.

GENERAL INFORMATION
Applicant Name: / Date:
By initialing each statement below, you are indicating that you understand and agree to the following requirements of the Title IV-E Child Welfare Training Program. Additionally, by initialing and then signing this form, you affirm that all information provided in this form is true and correct.

I agree to maintain good academic standing during enrollment in the Social Work program and to complete the entire required curriculum by my anticipated graduation date. “Good standing” is defined as maintaining a GPA of 2.00 or above for BASW students and 3.00 or above for MSW students.

I agree to participate in all Title IV-E required courses and focuses, practice labs, seminars, workshops, meetings and other trainings as required by the Title IV-E program.

I agree to complete a field placement in a public/tribal child welfare agency.

I agree to maintain a valid and non-restricted driver's license, automobile insurance for bodily injury, and use of an automotive vehicle at all times during my completion of this program.

I agree to be fingerprinted and to meet the criminal clearance requirements.

I agree to demonstrate a commitment to working in public/tribal child welfare serving families and communities consistent with the values of the NASW Code of Ethics.

I agree to sign a Title IV-E contract, legally committing to an employment obligation in public/tribal child welfare following graduation.

I hereby attest that I am eligible to work in the state of California, to receive federal funding through the Title IV-E program, and to commit to an employment obligation following graduation.

I hereby attest that I have never been convicted of a felony or a misdemeanor crime involving harm to children, or a violent crime against another person. Note: The criminal background clearance will disclose felonies and misdemeanors.

For full-time students: I understand that after graduation I must complete an employment obligationfor participating in the Title IV-E Child Welfare Training Program. The employment obligation must occur in a California public/tribal child welfare agency, and must meet the requirement of one year, full-time and continuous employment for each year of support provided in the program.

For part-time students: I understand that after graduation I must complete an employment obligationat my current California public/tribal child welfare agency for participating in the Title IV-E Child Welfare Training Program. The employment obligation must meet the requirement of (check one):

One year, full-time, and continuous employment for the BSW part-time program

Two year, full-time, and continuous employment for the MSW part-time program

For current child welfare employees: If I am an employee of a county child welfare or social service agency, I agree to provide as part of my application packet, the Agency Support form, completed by my agency’s administration, indicating approval of my participation in the Title IV-E Child Welfare Training Program as a full- or part-time student. The form will be submitted with my application packet.

I hereby attest that I have never been discharged from employment at a tribal, county or other social services agency due to violation of county code/merit system rules or violation of agency or professional code of ethics.

Please submit this form, with the application packet including all other application forms, to the CSU, Chico – School of Social Work Title IV-E Child Welfare Training Program.

Applicants Signature: ______Date: ______

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Revised 11.17.16mkm