APPLICATION FOR STIPEND
ULM Title IV-E BSW Child Welfare Training Project
ACADEMIC YEAR 2014-2015
Print or Type (dark blue or black ink only) to complete the following application. Be sure to complete all
parts.
PART 1 - Identifying Information
NAME _______________________________________
CWID #______________________
SOCIAL SECURITY NUMBER _____________________ DATE OF BIRTH ______________
ADDRESS (Include your permanent mailing address and a current address where you may be reached
during the semester):
Home __________________________________ Email Address
_______________________________________ ___________________________________
Campus (if other than home)
_______________________________________ Email Address
_______________________________________ ____________________________________
CURRENT TELEPHONE: __________________________ _________________________
(HOME)
(WORK)
__________________________
(CAMPUS)
SEMESTER YOU PLAN TO GRADUATE (Check one): ___ Fall 20___
__
Spring 20___
PART 2 - Academic Requirements
Current Overall GPA: ____________
GPA in Social Work (Major): __________
Your current ULM Social Work Advisor: ____________________________________
Semester you completed pre-social work admission criteria and were admitted to the
major: ____________________________
Indicate any academic clubs of which you are a member and/or any academic awards you have received
(attach additional page if required):
______________________________________ Date ____________________________
______________________________________ Date ____________________________
______________________________________ Date ____________________________
______________________________________ Date ____________________________
ULM Title IV-E BSW Child Welfare Training Project
Application, Academic Year 20__-20__
PAGE 2 OF 5
Indicate if you are currently enrolled in or have completed any of the following courses with a grade of A or
B received: SOCW 4008 and at least two additional courses from the following list must be completed.
Grade Received
Course
Semester Enrolled
(write “pending” if you are currently enrolled or
will be enrolled in)
SOCW 4008 Child Abuse & Neglect
SOCW 4001 Child in the Community
SOCW 4003 Family Violence
SOCW 4005 Differential Diagnosis
SOCW 3020 Case Management
SOCW 4010 Human Services
PSYC 2003: Child Psychology
PSYC 2005: Adolescent Psychology
CJUS 3008: Substance Abuse
CJUS 4015: Juvenile Delinquency
SOCL 4019 The Family
SOCL 2003 Social Problems
PART 3 - Contractual Requirements
1. Have you ever worked for a public social service agency before?
□ Yes If yes, when and where? _____________________________________
□ No
2. You will be required to complete one week La. DCFS New Workers Child Welfare Training. This will be
scheduled two weeks before or the week of beginning new semester. Locations vary from and may be
scheduled in Baton Rouge, Shreveport, Alexandria or Monroe. Typically, however, trainings are scheduled
in Baton Rouge. Expenses are covered for you, but this training almost always requires a full 4 days away
from home. Are you willing to accept these conditions?
□ Yes
□ No
3. Depending on availability of conferences during the semesters you participate, you will be required
to attend in-state and/or out-of-state conferences. Out-of-state conferences require air travel. These
expenses are not taken from the student stipend and are covered for students; you must, however, be
willing and able to travel by air out-of-state or travel by vehicle, usually with instructors or supervisors,
to in-state sites such as Baton Rouge or New Orleans. Are you able to accept this responsibility?
□ Yes, no limitations
□ Yes, with the following limitations _______________________________________________
□ No, I cannot accept this responsibility because ____________________________________
ULM Title IV-E BSW Child Welfare Training Project
Application, Academic Year 20__-20___
PAGE 3 OF 5
4. Upon graduation you must complete the Civil Service Job Application on the listed website
(http://agency.governmentjobs.com/louisiana/) and apply for the Title IV-E Social Services Specialist
Intern position for employment, if positions are available to you, in Louisiana. You may elect to
continue straight from your undergraduate degree to you graduate degree in social work, which you
will be encouraged to do. If you elect to continue to your graduate degree, this will be considered an
allowable deferment; you will be able to fulfill your employment obligation to work in Louisiana’s public
child welfare agency (called the Department of Children & Family Services or DCFS) after completion
of your graduate degree. If you apply and are accepted as a Title IV-E participant, this obligation must
be met under penalty of repayment. Are you willing to accept this responsibility to work for Louisiana
DCFS upon graduation from ULM?
□ Yes, I will likely seek employment immediately after graduation from ULM.
□ Yes, but I will likely seek MSW and defer La. DCFS employment.
□ No, I do not anticipate that I would be able to seek La. DCFS employment because
______________________________________________________________________
5. Employment with La. DCFS is enhanced if you are willing to work anywhere in the state. If you are
selected, were in the state would you most like to work? Please number the areas listed below from
place of [1] greatest desire to work to place of [5] least desire to work.
_____Northeast Louisiana (Monroe and surrounding area)
_____Northwest Louisiana (Shreveport and surrounding area)
_____Central Louisiana (Alexandria and surrounding area)
_____Capitol (Baton Rouge and surrounding area)
_____South Louisiana (New Orleans and surrounding area)
6. If you are selected, you must complete a field placement in a DCFS Parish Office in Region IX
(Northeast LA). Eleven parishes comprise the DCFS Region IX catchment area, any one of which you
may be assigned to depending on availability of DCFS field supervisors. Please number the following
parishes from Office of [1] greatest desire to work to the office of [8] least desire to work.
_____Ouachita/Caldwell (Monroe & Columbia)
_____Richland/West Carroll (Rayville & Oak Grove)
_____Tensas/Madison (St. Joseph & Tallulah)
_____Union (Farmerville)
_____Lincoln (Ruston)
_____Morehouse (Bastrop)
_____East Carroll (Lake Providence)
_____Franklin (Winnsboro)
ULM Title IV-E BSW Child Welfare Training Project
Application, Academic Year 20__-20__
PAGE 4 OF 5
7. You must be willing to participate in a research follow-up study. This is directed by State
DCFS. Are you willing to participate?
□ Yes
□ No
8. You must complete a prescreening for transportation clearance for placement in a DCFS
Parish office. You must have your own vehicle (at time of application) to get to work and have
adequate auto insurance (at time of application). Please provide the following information:
Driver’s License Number _____________________ State ________ Expiration date _________
Are there any limitations on your license?
□ Yes □ No
9. Prior to placement in a DCFS agency for field internship, you must complete a criminal history
check and a random drug screen (date assigned after selection), conducted by DCFS if you are
selected. If these are not clear, indicating previous criminal activity, particularly child molestation,
or that drugs/alcohol are currently being used, you will be immediately dismissed from
participating in Title IV-E, with no stipend award or repayment of any award you may have
received.
Are you willing to accept these conditions?
□ Yes, no personal concerns
□ Yes, with the following personal concern ________________________________________
□ No, because of the following concern ___________________________________________
Part 4 - Background, Experiences & Motivation
1. What paid or volunteer experience have you had in work with children and/or families?
(Names, dates, types of experience may include any work done with children and parents and
may include high school, church and community experiences)
ULM Title IV-E BSW Child Welfare Training Project
Application, Academic Year 20__-20__
PAGE 5 OF 5
2. Why do you wish to pursue a career in Child Welfare Services, particularly with the Louisiana
DCFS (which includes Child Protection, Family Services, Foster Care, or Adoptions)?
3. What contribution do you feel you can make to the field of Child Welfare Services within the
Louisiana DCFS or other state child welfare agency?
Part 5 - References
Provide the names and addresses of three people not related to you who will provide a
reference. Include at least one who can address your work with children and families, even if you
have only done such work as a volunteer. You must request of each reference listed a completed
“Student Stipend Reference Form” and ask that it be mailed directly to ULM.
NAME ___________________________________
Address _________________________________
___________________________________
___________________________________
NAME ___________________________________
Address _________________________________
___________________________________
___________________________________
NAME ___________________________________
Address _________________________________
___________________________________
___________________________________
Phone ________________________
Phone _________________________
Phone _________________________
APPLICANT SIGNATURE _________________________________DATE________________