Social Work Field Experience Application

Only the Field Director, Department Chair, or a Social Work Faculty Member is required to review this application. At the discretion of the Field Director, others may be asked to contribute.

Which campus do you attend? *

Contact Information

Personal Information

Emergency Contact Information

Background Information - The following questions are used to assess the student's eligibility for field placement in agencies requiring criminal background checks.

Have you ever been convicted of a felony? *
Have you ever been convicted of assault or sexual misconduct with a child? *
Have you ever had your driver's license revoked? *
Have you ever been terminated from a position? *

Agency Placements - Please list your top three preferences for agency placement or general practice area. The Field Coordinator will evaluate student needs/preferences and agency's requirements/needs in securing placement sites. However, no guarantee is made to place students in their preferred setting.

Are you currently (or have you ever been) a client of a prospective placement agency? *

Upload Required Documents

Statement of Acknowledgement

Field Experience Manual Certification *

 Certification: I hereby certify that the answers and statements contained in this application are true to the best of my knowledge and belief. Checking this box serves as your digital signature.

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