Winthrop University
Department of Social Work
Application for MSW Field Instruction
**Please type or print clearly
Date: ______________________________
Name: _______________________________________________________________________
Local address: _______________________
Phone: _____________________________
___________________________________
Winthrop email:______________________
Home Address: ______________________
Cell Phone: _________________________
___________________________________
Home Phone: _________________________
___________________________________
Work Phone: _________________________
Do you have a valid Driver’s License?
Yes_____
No _____ State: _________
License Number: _________________________________
Expected date of graduation: ____________
GPA
Car available? Yes ____ No ____
Advisor: ____________________________
_____________________________
Do you anticipate being employed during the field placement?
Yes_________ No__________
If yes, how many hours per week do you anticipate working? _______________
If yes, write a brief description of how you plan to balance the requirements of field placement
and course work with the requirements of your paid work?
(Attach an additional page.)
Do you require any special accommodations in your field course/field placement? ___Yes ____No
If yes, please explain: ______________________________________________________________
________________________________________________________________________________
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.
Each student applying for a field placement is required to turn in the following information
several days prior to their field appointment:
1. Completed application for field
2. Current resume
3. Essay - typed, double- spaced and not exceed three pages.
Content of the essay should:
1. Describe any special skills you possess; such as interviewing, problem solving, crisis
intervention etc. Include any personal attributes or characteristics that you feel would be
assets to you as a social worker, incorporate any limitations or weaknesses that you feel
need to be addressed in field work.
2. Summarize the salient aspects of your volunteer or paid work experiences and class
experiences.
3. Identify the types of learning experiences that you want to gain from your field placement.
4. What are your professional goals? Where do you expect to be in five years? Ten years?
5. 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 FORM
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.
Date_________________
___________________________________
Signature