Rev 2015
Winthrop University
Department of Social Work
Application for BSW Field Instruction
**Please type or print clearly.
Name :
WU E-mail Address:
Address:
Do you have a valid Driver’s License?
Do you have transportation available?
CWID:
Primary Phone Number:
_____Yes _____ No
_____ Yes _____ No
If yes, which state: ________
Volunteer or Paid Human Services Experience:
Agency:
Supervisor:
Date(s):
Expected date of graduation:
GPA (Overall):
Academic Advisor:
SCWK GPA:
Social Work Course Grades and Semester Completed
Course #
SCWK 200
SCWK 305
SCWK 306
SCWK 321
SCWK 330
SCWK 430
SCWK 431
SCWK 432
SCWK 433
Course Title
Introduction to Social Work
Human Behavior in the Social Environment
Working with Multi-Cultural Populations
Social Welfare as a Social Institution
Research Methods for Social Work
Social Work Intervention I
Interpersonal Helping Skills in Social Work
Social Work Intervention II
Social Work Intervention III
Grade
Semester
List any course other than SCWK 443 and SCWK 463 you have left to take before graduation:
__________________________________________________________________________________________
Do you require any special accommodations in your field placement?
If yes, please explain:
_____ Yes _____ No
Have you ever been convicted of a crime other than a minor traffic offense? _____ Yes _____ No
If yes, please explain:
Some field agencies require that students meet additional requirements prior to admitting them to the agency for
placement. These might include a criminal background check, immunization screenings, drug screenings,
employee/volunteer training classes etc. It is the student’s responsibility to complete, and if needed, pay for
these additional requirements. Please note that the field office cannot guarantee a field placement if you are
unable to successfully pass agency drug screenings and criminal background checks. Please openly and
honestly discuss any concerns you may have regarding these issues with the Field Director.
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Rev 2015
Each student applying for a field placement is required to turn in the following information prior to their
field appointment:
1. Completed application for field
2. Current resume
3. Signed Social Work Termination Policy
4. Essay – typed, double-spaced and not to exceed three pages
Content of the essay should:
1. Describe any special skills you possess; such as interviewing, problem solving, crisis intervention etc.
2. Discuss any personal attributes or characteristics that you feel would be assets to you as a social worker.
3. Discuss any limitations or weaknesses that you feel need to be addressed in field work.
4. Summarize the salient aspects of your volunteer or paid work experiences and class experiences.
5. Identify the types of learning experiences that you want to learn from your field placement.
6. Include any additional information that you think would be helpful in making the decision regarding
your placement.
List in order of preference the type of agency in which you are most interested.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
FIELD INSTRUCTION RELEASE OF INFORMATION
I hereby authorize the Field Director for the Department of Social Work to release and share with any potential
and/or assigned field instructor, information from my academic record that could assist me in the successful
selection and completion of the field experience. This release is granted until I complete my field experience.
Signature
Date
ACKNOWLEDGEMENT OF RISK IN FIELD
I have read the Acknowledgement of Risk in Field document and understand that the field practicum may
present some risks. I also understand that prudent choices and exercising caution can minimize these risks. I
further recognize that it is my responsibility to become informed of agency policy and practices regarding safety
in the field.
Signature
Date
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