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

Which campus do you attend? * Alva Enid Woodward Other

If other, which location?

Contact Information

Name (include title, first, middle, last names) *

Mailing Address (Street Address, City, State, Zip) *

Phone *

Email Address - (NWOSU Email Address Required) *

Personal Information

Date of Birth *

Citizenship *

Please list any scheduling concerns that may occur during your practicum, i.e. Caregiver for small children, disabled, elderly adult)

Please list any health concerns that may impact completing a successful Field Experience:

Emergency Contact Information

Emergency Contact's First and Last Name *

Emergency Contact's Phone Number and Email Address *

Relationship to Applicant? *

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? * Yes No

If yes, please provide the date, place & charges:

Have you ever been convicted of assault or sexual misconduct with a child? * Yes No

If yes - please provide the date, place and charges:

Have you ever had your driver's license revoked? * Yes No

If yes, please provide the date, place and charges here:

Work and Volunteer Experiences: *

Have you ever been terminated from a position? * Yes No

If Yes, please explain:

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.

Top three preferences for agency placement or general practice area *

Are you currently (or have you ever been) a client of a prospective placement agency? * Yes No

If Yes, please explain:

Upload Required Documents

Transcripts - Unofficial transcripts are accepted *

Degree Audit *

Copy of Driver's License *

Automobile Insurance *

Professional Liability Insurance *

Resume *

Statement of Acknowledgement

Field Experience Manual Certification * Yes No

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.

Social Work Field Experience Application