Department of Social Work, Meiklejohn Hall, room 4064
(510) 885-4916 / (510) 885-7580 Fax
http://class.csueastbay.edu/socialwork/Apps
DEPARTMENT APPLICATION
FOR THE
HAYWARD CAMPUS FULL-TIME
MASTER OF SOCIAL WORK PROGRAM
Instructions: Please complete: 1) the department application; 2) a personal statement; 3) application
checklist; 4) field application; 5) attach your resume; 6) three sealed letters of reference with cover
sheets; and 7) one complete set of official transcripts (in sealed envelopes) from each college or
university previously attended and mail to:
California State University East Bay
Department of Social Work, MI 4064
25800 Carlos Bee Blvd.
Hayward, CA 94542
Date Submitted: ___/___/____
Application for Fall Quarter (year):
__________
Program Concentration: Children, Youth & Families (CYF) ___ Community Mental Health (CMH) ____
Personal Information
First Name: _____________________________ MI___ Last Name:__________________________
Other names previously or currently being used:____________________________________________
Date of Birth: ___/___/___
Gender: F  M 
Race/Ethnicity: ____________ or if you choose to decline, please check the box 
Soc. Sec.#: _______________________
Net ID(if former CSUEB student): _______________
Address: ___________________________________________________________________________
Street
City
State
Zip
Phone Numbers: Home____________________________ Work______________________________
Cell: ____________________________ Email Address: _____________________________________
Emergency Contact
Name: __________________________________________Relationship: _________________________
Address: ______________________________________________________Phone: ________________
Work Phone: _________________________ Email Address: ___________________________________
Prerequisites Completed
Statistics:
_____________
University
Human Biology:
_____________
University
_________
Course #
_________
Course #
_______________
Course Title
_______________
Course Title
________
________________
Grade
Date Completed
________
________________
Grade
Date Completed
Undergraduate information
Type of degree: _____________Major: ______________________________________GPA: _________
Institution: ___________________________________________ Date of Degree: __________________
Foreign Language Skills
Are you proficient in any language other than English?
Yes __ No__
If yes, which language(s)? _____________________________________________________________
Criminal History/Professional Liability Consent
Have you ever been convicted of a felony? If yes, please explain________________________________
____________________________________________________________________________________
All applicants are required to consent to a criminal background check and purchase student
liability insurance (nominal fee) prior to agency placements. If your criminal record prevents
you from securing a field placement and/or you do not obtain student liability insurance, you
will not be able to remain in the MSW program.
I, ________________________________ agree to submit to a background clearance check and purchase
student liability insurance prior to my being placed in an agency.
_____________________________
Your signature
_________
Date
Social Work Application Statement:
As part of your application for admission to the MSW program at CSUEB, you are to write a statement
that addresses the six questions listed below. This statement will be used to assess your writing skills
and to aid the Admissions Committee in making a decision about your application. Your statement
should not exceed five typewritten pages, double-spaced.
A.
B.
The concept of “cultural pluralism” which plays an important role in social work,
emphasizes respect for diversity of values, heritages, customs and lifestyles.
1.
What experiences have you had that make you feel that you can work effectively with
people from diverse populations reflecting racial, ethnic, handicap status, socioeconomic, gender and sexual orientation differences?
2.
What difficulties, if any, do you feel that you might have in working with any of the
populations listed above?
3.
What experience have you had in dealing with ageism, homophobia, racism, sexism, or
other forms of oppression?
The profession of social work is committed to social justice.
1.
What do you understand the concept “social justice” to mean?
2.
How do you plan to promote social justice with your MSW?
3.
What experiences or factors shaped your interest in advancing social justice?
Experience and Employment History
Please list up to four of your most significant paid job experiences and/or volunteer experiences during
the last 10 years.
1. Agency/Center: __________________________________________________________________
Address: ______________________________________________ Phone: __________________
From: ______________
To: ______________ Title: ___________________________________
Salaried or Volunteer position?:________________ Supervisor:____________________________
Responsibilities: __________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2. Agency/Center: __________________________________________________________________
Address: ______________________________________________ Phone: __________________
From: ______________
To: ______________ Title: ___________________________________
Salaried or Volunteer position?:________________ Supervisor:____________________________
Responsibilities:
_______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3. Agency/Center: __________________________________________________________________
Address: ______________________________________________ Phone: __________________
From: _____________
To: ______________ Title: ____________________________________
Salaried or Volunteer position?:________________ Supervisor:____________________________
Responsibilities:
_______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4. Agency/Center: ___________________________________________________________________
Address: ______________________________________________ Phone: ___________________
From: _____________
To: ______________ Title: _____________________________________
Salaried or Volunteer position?:________________ Supervisor:_____________________________
Responsibilities:
________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________