Social Work Field Education Program

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SOCIAL WORK FIELD EDUCATION PROGRAM

GRADUATE SOCIAL WORK FIELD APPLICATION – PART 1

Last Name: First Name: Middle Initial: Maiden (if applicable):

Address during field placement:

Street: City: State: Zip:

Permanent Address (if different):

Street: City: State: Zip:

Primary Telephone Number:

Panther E-Mail Address: Expected Date of graduation:

Are you a: Full-time student Part-time student

Please enter all semesters for the upcoming field practicum: / Please check all of the Field Course Numbers you are applying for with this field placement.
·  2-semester placements require 2 courses to be checked.
·  3-semester placements require 3 courses to be checked.
721 260 hours / 3 credits
20FALL SEMESTER / 722 260 hours / 3 credits
20SPRING SEMESTER / 821 320 hours / 4 credits
20SUMMER SEMESTER / 822 320 hours / 4 credits
921 260 hours / 3 credits or 320 hours / 4 credits

·  Do you have an approved exemption for Field Course 721? (Please attach) Yes No

·  Do you have an approved exemption for Methods Course 708 or 709? Yes No

·  Are you in the Direct Practice Track? Yes No

·  Are you in the Macro Practice Track? Yes No

·  Are you in the Direct Practice / Macro Practice Double Concentration track? Yes No

·  SW Concentration Area: (Check One) Mental and Behavioral Health

Physical Health

Gerontology

` Children and Families

Community and Organizational Leadership

Double Concentration

·  Do you plan to complete any of the following certificate programs?

·  Trauma Certificate Yes No Unsure

·  Applied Gerontology Yes No Unsure

·  Non-Profit Management Yes No Unsure

·  School Social Work Yes No Unsure

*If you checked “yes” for School Social Work, contact Timothy Schwaller at 414.229.4695 or

to determine if you need a field placement with children / adolescents.

·  Do you plan to pursue your LCSW (Licensed Clinical Social Worker)? Yes No Unsure

·  Do you plan to pursue your Substance Abuse Certification? Yes No Unsure

Indicate the times each day that you are available for Field Placement.
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Hours Available

·  Please add any additional comments about your availability:

EDUCATION:

Please start with current enrollment at UW-Milwaukee and include all additional academic and professional education beyond high school.

Institution & Location / Major / From - To / Degree and Year

·  Will you maintain employment during your field placement? Yes No

·  If you answered “yes,” will you be working full-time or part-time during your field placement?

·  Full-Time Part-Time

·  Name of Employer & City / State:

·  Type of Work:

·  Hours per Week:

PAID SOCIAL WORK AND HUMAN SERVICE EMPLOYMENT:

Name & City of Employer / Title / Full-time / Part-time / Specific Duties/
Responsibilities / Dates

OTHER EMPLOYMENT: PAID OTHER EMPLOYMENT INCLUDING MILITARY SERVICE

Name & City of Employer / Title / Full-time / Part-time / Specific Duties /
Responsibilities / Dates

VOLUNTEER EXPERIENCE:

Name & City of Agency / Title / Specific Duties /
Responsibilities / Dates

List the full name of all professional credentials, licenses, and certifications you currently have.

UNDERGRADUATE FIELD PRACTICUM INFORMATION:

·  Please complete if you have had a previous undergraduate field placement experience in either Social Work or another academic discipline.

1.  Agency name and city to which assigned:

From: To:

List specific duties and responsibilities of your field work:

2. Agency name and city to which assigned:

From: To:

List specific duties and responsibilities of your field work:

GRADUATE FIELD PRACTICUM INFORMATION:

·  Please complete if you have had a previous graduate field placement or are currently involved in a graduate field placement in either Social Work or another academic discipline.

1. Agency name and city to which assigned:

From: To:

List specific duties and responsibilities of your field work:

2. Agency name and city to which assigned:

From: To:

List specific duties and responsibilities of your field work:

GRADUATE SOCIAL WORK COURSES:

·  Please list all elective Social Work courses you have completed, are currently taking, or will be taking during this field placement:

FOREIGN LANGUAGE PROFICIENCY:

·  Are you proficient in a foreign language? Yes No

·  If you are proficient in a foreign language, indicate which language / languages:

7/11/2017

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SOCIAL WORK FIELD LIAISON SELECTION:

·  Please refer to the Social Work Practice Areas form and the Liaison Selection Template form to determine your Social Work Field Liaison choice.

·  Please check the box for the Social Work Field Liaison that you intend to register with for your field placement.

·  If you need additional information prior to making your Field Liaison selection, please contact Jeanne Wagner, Director of SW Field Education, at (e-mail) or 414-229-6501 (phone).

Amy Kirby / Crystal Carter
Candace Coates / Jeanne Wagner
Devin Thomas / Johanna Barkei
Jennifer Kahn-Pettigrew / Timothy Schwaller

FIELD PRACTICUM PRACTICE AREA OF INTEREST INFORMATION:

Check the specific Social Work Practice Area you want to explore for your field practicum:

Child & Youth / Adolescent / Family
Public Child Welfare / Child Protective Services
Mental / Behavioral Health / Substance Abuse
Geriatrics
Corrections / Criminal Justice
Medical / Hospice
School Social Work / Poverty Support Programs / Homelessness
Developmental, Cognitive and/or Physical Disabilities
Refugee Services
Veterans Services
Domestic Violence
Bereavement
Other Describe:

1.  Describe the learning experiences you want to gain from this specific field practicum.

2.  Describe your career objectives in the social work profession following graduation.

3.  Describe any professional skills you have which you would like a potential field agency to be aware of.

4.  List the full name of all completed trainings, workshops, continuing education, etc. which might be helpful to you in your field practicum.

5.  Do you have the use of a personal vehicle during your field placement? Yes No

6.  Specify any transportation needs and / or limitations:

My signature below authorizes the sharing of this application with field agencies as part of the field placement process in preparation for a field practicum interview.

Student Signature: Date:

7/11/2017