Department of Social Work
MSW Field Internship Application –
Concentration Year
Campus-Based
Foundation Year
Student Information
@
Student ID:
Date:
Full Name:
Last
First
M.I.
Street Address during Internship
Apartment/Unit #
City
State
ZIP Code
Home Address
(if other than above):
Street Address
Apartment/Unit #
City
State
Primary
(
Phone:
University E-mail
Address:
)
(
Alternate Phone:
ZIP Code
)
@scots.edinboro.edu
Emergency Contact Information
Full
Name:
Last
Primary Phone:
First
(
)
Alternate Phone:
M.I.
(
)
Relationship:
Field Questionnaire
Please check each item accordingly:
Will you have a car for transportation?
Do you speak another language?
Will you be employed during the academic year?
YES
NO
If YES, specify:
If YES, specify # hours per week:
Rank the following areas of interest to assist in determining your field practicum site. (List from first to last
beginning with the most preferred.)
Mental Health
FIELDS OF PRACTICE
Medical
Chemical Dependency & Addiction
Treatment
Child Welfare / Family Services
Community Center
School Social Work
Military / Veteran Affairs
No Preference
Location preference (check one):
Erie
Meadville
Either Erie or Crawford County
Other: specify
Community / Policy Development
Aging
Residential Treatment
Crisis Intervention
Other: Specify
1.
2.
3.
What do you want to accomplish during your field internship? Please be specific.
List any special circumstances or accommodations to be considered in arranging your field internship
experience:
NOTE:
 Please attach:
o Your updated professional resume
 Sign and date permission to release information
Permission to Release Information
Consent: I give my permission to share this information with prospective field internship agencies.
 YES
 NO
Date:
PLEASE NOTE: The following information MUST BE submitted ONE MONTH prior to the start of the
student’s internship. No student will be allowed to begin his/her placement without providing the Social Work
Field Office with copies of the documents listed below. All documents must be current within one year of the
start of the student’s placement.
 Student Malpractice Insurance Certificate ($1,000,000 / $3,000,000) (Requires NASW Membership)
 PA Child abuse history clearance (Act 33) or date of application
 FBI Fingerprint/Background Check via Dept. of Human Services (previously Dept. of Public Welfare)
 PA State police request for criminal record check (Act 34) or date of application