advanced_standing_msw_field_internship_application.doc

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Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861 APPLICATION FOR MSW FIELD INTERNSHIP SPECIALIZATION YEAR 2018-2019 Directions: Please complete, print, and submit an original application to the MSW Program Office by the specified deadline. After submitting your application, you may sign up for a field pre-placement interview with the field faculty. Students will receive an email with a link to sign-up for interviews once this application is submitted to the MSW Program Office. Students with limitations or who anticipate problems fulfilling field requirements are required to sign up for an interview by calling the above number. Date of Application: I. STUDENT INFORMATION Name: Student ID# Local address: Date of birth: City: State & Zip: Gender: Male Female Permanent address: Phone number: City: State & Zip: Cell Phone: If you plan to move, please give the approximate date and geographic location: Please notify MSW Program of any address or email changes throughout the academic year to avoid a delay in correspondence APU Email address: Emergency contact & phone number: Citizenship status: Undergraduate Degree and Major: II. FIELD PLACEMENTS – Check the types of populations/settings you are interested for Specialization Year internship *Community Specialization only: add area of emphasis Program Planning/Management and Fundraising/Grants Community Development/Organizing/Local Government Policy and Advocacy/Research & Analysis Populations: Adults Child Welfare Children/Adolescents Corrections Developmental Disabilities Domestic Violence Early Intervention (0-5) Foster Families/Adoptions Forensics Gangs/Youth Violence HIV/AIDS Homelessness/Housing Services Hospice/Palliative Care Immigration/International/Human Rights Healthcare/Medical/Hospital LGBT Local Government/Policy Mental Health Military/Veterans Older Adults School-Based Mental Health Substance Abuse/Addictions Transitional Age Youth (18-21) 1 Cohort: 1-yr. Advanced Standing Full-Time 2-yr. Advanced Standing Part-Time 2-yr. Full-Time 4-yr. Part-Time Specialization: Clinical Practice with Individual and Families Community Leadership and Program Administration Insert Copy of Valid California Driver License
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Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861 List the three areas that interest you the most for Specialization Year: 1. 2. 3. List the three areas that interest you the least : 1. 2. 3. III. INFORMATION ABOUT PREVIOUS FIELD INTERNSHIP Name of field internship: Name of agency field instructor: Age group primarily served at internship (check all that apply) Children Adolescents Young Adults (Transitional Age Youth, ages 18-24) Adults Older Adults Identify three social work practice skills that you learned/applied in your previous field internship: 1. 2. 3.
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  • Winter '16
  • ProfessorDuncan
  • Master of Social Work, Department of Social Work

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