STUDENT CHOICE OF PLACEMENT
Please complete your interviews with agencies April 4th – May 4th and return this form to the Field
Office NO LATER THAN May 7, 2012.
You must be a student in good academic standing before beginning a second placement, i.e., a G.P.A. of 3.0
and no more than 6 credits of incompletes. You must have also completed all prerequisites for your field
course.
Yes, I am a student in good academic standing and have completed all
field prerequisites.
Student Signature
Date
Placement assignments will be made and confirmations will be put in your student mailbox or mailed to you at the
address below provided all information is submitted by the required dates. Please complete all of the material below.
Name
Address
Date
Home Phone
Work Phone
Concentration:
____ Direct Practice
E-Mail
Program:
____ Community Practice
WeekDAY:
WeekEND:
____ 50 Credit
____ Advanced Standing
Full Time:
Part Time:
Placement: _________ 8010 - first placement
_________ 8020 - second placement
_________ 8030 - advanced standing placement
Are you a IV-E scholar? ___________
My previous placement was with:
Have you ever worked in any of the agencies listed below?
If yes, please specify agency name and dates of employment.
(You will also need to submit an application for internship at place of employment.)
Please list below the full names of your agency choices in order of preference. List only those agencies where you
have interviewed and where you are interested in doing your field placement. DO NOT INCLUDE AGENCIES
WHERE YOU WOULD NOT BE WILLING TO BE PLACED! Be sure to rank them in order of your
preference for internship sites and give specific contact information for each agency on the backside of this
form. It is critical that this form be filled out completely on both the front and backsides to give you the best possible
chance of getting a placement in one of your preferred agencies. Please use an extra sheet of paper for additional
choices. Thank you.
1.
2.
3.
4.
5.
1. First Choice Agency
Agency Name:
Field Instructor(s):
Address:
Phone:
Field Instructor(s) Email:
Notes:
2. Second Choice Agency
Agency Name:
Field Instructor(s):
Address:
Phone:
Field Instructor(s) Email:
Notes:
3. Third Choice Agency
Agency Name:
Field Instructor(s):
Address:
Phone:
Field Instructor(s) Email:
Notes:
4. Fourth Choice Agency
Agency Name:
Field Instructor(s):
Address:
Phone:
Field Instructor(s) Email:
Notes:
5. Fifth Choice Agency
Agency Name:
Field Instructor(s):
Address:
Phone:
Field Instructor(s) Email:
Notes:
Is the placement paid?
Zip Code:
Amount?
Is the placement paid?
Zip Code:
Amount?
Is the placement paid?
Zip Code:
Amount?
Is the placement paid?
Zip Code:
Amount?
Is the placement paid?
Zip Code:
Amount?
Please Return to:
Rosetta Chears, Field Program Coordinator
University of Minnesota - School of Social Work
105 Peters Hall, 1404 Gortner Ave., St. Paul, MN 55108
PHONE: 612-624-4241, FAX: 612-624-5245