MSW Field Practicum Application

MSW Field Practicum Application

Foundation Practicum - SOWK 551
Advanced Practicum - SOWK 653

If you are filling this form out as an employee, please be sure to follow the link here to fill out the employee form afterwards.

  • Name (required) Name (required) *
  • Address (required) Address (required) *
  • Phone (required) Phone (required) * - -
  • Education

  • Degree/Date of Graduation Degree/Date of Graduation / /
    Pick a date.
  • Employment History

  • Are you currently employed? (required) *
    Are you currently employed? (required)
  • Current Employer Address Current Employer Address
  • Current Employer Phone Current Employer Phone - -
  • Former Field Placement(s)

    If applicable - include BSW or Foundation experience

  • Date Date / /
    Pick a date.
  • Personal Information

  • Are you going to do an employee based placement? (required) *
    Are you going to do an employee based placement? (required)
  • Other pertinent information

  • Valid driver's license
    Valid driver's license
  • Have you ever been convicted of a misdemeanor or felony?
    Have you ever been convicted of a misdemeanor or felony?
  • Have you ever had a professional license denied, suspended, or revoked in any state or country?
    Have you ever had a professional license denied, suspended, or revoked in any state or country?
  • In case of emergency, notify: In case of emergency, notify:
  • Statement of Understanding and Concent

    Statement of Review of NASW Code of Ethics, MSW Program Student Handbook, and MSW Field Manual
    I have reviewed and agree to adhere to the NASW Code of Ethics and policies outlined in the Concord University MSW Program Student Handbook and the MSW Practicum Manual. I understand my responsibilities and ethical commitments as a social work student at CU and as a future professional social worker.

    Statement Regarding Academic Performance
    I understand that I must meet the minimum GPA of a B or better in all required social work classes and I must pass SOWK 653a in order to proceed to SOWK 653b, and I must pass 653b in order to proceed to 653c. I understand that academic misconduct is unethical and includes but is not limited to plagiarism (copying others’ work and claiming it as your own, failing to use proper citations, cheating on tests and homework assignments and copying or purchasing papers from the internet or other sources).

    Statement of Commitment to Work toward Professional Competence
    I understand that I must demonstrate minimal levels of effective performance when interacting with clients and coworkers. I must provide evidence of: following the agency’s personnel practices; maturity; openness to differences; respect of learning from others including my clients; openness to learning and constructive feedback from my supervisor, faculty, coworkers and colleagues; complete all assigned tasks; self-reflection; and mastery toward the necessary skills for interpersonal helping.

    Statement Regarding Background Checks
    I am aware that background checks may be required for some placements and may also affect my future in social work. My signature indicates that I am fully aware I may be required to obtain a background check for criminal convictions, child abuse and neglect, and my driving record. These background checks may be required for my practicum and/or future employment. I understand that I may discuss any information with the Director of Field Education and will be advised about any implications of the information shared.

    Statement Regarding Release of Information to Potential Field Instructors, and/or Agency
    I understand the Director of Field Education will be contacting potential field instructors/agency in an effort to secure a placement on my behalf. I, therefore give the Director of Field Education permission to release pertinent and relevant information about me to potential practicum agencies and their representatives. This release will be valid up to two years from the date this agreement is signed.

    Statement of Understanding of the Practicum Placement Process
    I understand that I must complete all the steps of the Field Placement Process by the designated dates provided by the Director of Field Education. I understand that failure to do so will jeopardize my placement in an agency/school for my practicum.

    My signature below indicates that I have read and concur with the above statements.

  • Clear
  • Date Date / /
    Pick a date.