BSW First Practicum Application Form
University of Missouri-St. Louis
School of Social Work (rev 1/2016)
Semester for which Practicum is being requested
Fall ☐
Year 20
Spring ☐
Summer ☐
Faculty Advisor:
Date accepted into the BSW Program: Semester:
☐I have not yet been admitted into the BSW program.
Year:
□
In addition to a BSW, I am pursuing a certificate in: ☐ Gender Studies
CAST
Did you complete a practicum/internship for your Associate’s Degree? ☐ Yes ☐ No
If yes, what is the name of the agency?:
I.
Personal Data:
Name:
Student #
Home Address
Street
City/State
Zip
Email address:
Phone numbers: Cell:
Home:
Expected Date of Graduation:
Minor
Person to notify in an emergency:
Address
Phone #:
Email:
II Academic Pre-requisites:
You must have 90 hours of course work including math competency completed and a
minimum GPA of 2.5 in social work and related areas and to be eligible for practicum.
Indicate the number of hours that will be completed at the end of the current semester:
Current BSW GPA:
Math course number:
Semester taken:
Completed (yes/no/IP)
1
Grade
The following is a list of courses required to receive a BSW. Check all those that are
completed or are in the process of completion.
A. Professional Foundation Courses:
Course Number
Completed (Yes/No)
Grade
Semester
Taken
Completed (Yes/No)
Grade
Semester
Taken
Grade
Semester
Taken
SW 2000 or equivalent if taken at STLCC
SW 2200 or equivalent if taken at STLCC
SW 2001 or equivalent if taken at STLCC
SW 3100
SW 3210
SW 3510
SW 3700
SW 4110
SW 4300
SW 4350 (if applicable)
B. Area Requirements:
Course Number
BIOL (Please indicate course number)
SOC 1010
PSYCH 1003
ECON 1000 or Econ 1005
POL SCI 1100
SOC/PSYCH 2160
Statistics Requirement (Only one course should be selected in this area)
Course Number
Completed (Yes/No)
SOC 3220
CCJ 2220
PSYCH 2201
If other please indicate course information below
2
Research Requirement (Only one course should be selected in this area)
Course Number
Completed (Yes/No)
Grade
Semester
Taken
SOC 3230
SW 3410
CCJ 2210
PSYCH 2219
If other please indicate course information below
C. General Education Requirements (for the University):
☐ Three Humanities Courses
☐ Four Natural Sciences or Mathematics Courses or a combination of the two totaling 12 credit hours.
☐ Cultural Diversity
☐ Math Proficiency (Math 1030 or 1020)
☐ Freshmen Composition English 1100 or equivalent
☐ Advanced Expository Writing Junior Level English 3100
☐ American History and Government Requirement
III. Practicum Information
Social Problems/Target Populations in which you are interested:
Career Plans:
Agency Preferences:
3
Name of agency, address, phone number and contact person:
A.
B.
C.
D.
E.
Student Signature:
Date Submitted:
Faculty Advisor’s Signature:
Date Signed:
Agency(s) Approved:
A☐
B☐
C☐
Date Approved:
Assistant Director of Field Education Signature:
4
D☐
E☐