BSSW APPLICATION COVER SHEET
IDENTIFYING INFORMATION:
NAME
TECH ID#
LAST
FIRST
MIDDLE
Place a “ ” in the box by either the ‘Local Address’ or ‘Permanent Address’ to let the Department know which address to
use for formal correspondence. Consider if you will be moving in the next 3 months when completing this!
LOCAL ADDRESS
STREET/BOX
CITY
STATE
ZIP
PERMANENT ADDRESS
STREET/BOX
CITY
STATE
TELEPHONE NUMBERS W/ AREA CODE:
(
)
|(
)
LOCAL
*MAVMAIL ADDRESS:
PERMANENT
ZIP
|(
)
CELL
*Faculty will communicate with you using your Mavmail email address; Check Mavmail account routinely.
PRINT STUDENT NAME: _______________________________________________________
I understand that my signature indicates that I have met with my BSSW program faculty advisor to
review my application. I have thoroughly reviewed all components and my application is accurate and
complete to the best of my knowledge. I understand that an incomplete application may result in my
application not being reviewed in a timely manner.
___________________________________________________________________________
STUDENT SIGNATURE
DATE
PRINT ADVISOR NAME: _______________________________________________________
I have met with the student applicant and reviewed the BSSW Program application.
_________________________________________________________________________
ADVISOR SIGNATURE
DATE
COMPLETED APPLICATION STATEMENT
I, (name) ___________________________ (Tech ID) _________________, respectfully submit my
completed application for consideration for admission to the BSSW program at Minnesota State
University, Mankato. I have reviewed all documents related to the Application and have included the
following documents in this application packet.






BSSW Program Application Form SIGNED and DATED by student applicant and BSSW faculty advisor.
Professional Resume.
Letter of Request for Exception(s) (if needed).
Degree Audit Reporting System (DARS) report with a cover sheet signed by CSBS Advising U staff.
Supplemental transcripts and/or substitution/waiver forms (if needed).
SIGNED and DATED BSSW Program Academic and Professional Behaviors Statement of
Responsibilities Contract.
 3 Essays per instructions.
 Other documents (if needed).
REQUEST FOR EXCEPTIONS, NOTICE OF ACADEMIC OR PROFESSIONAL CONCERNS, AND SUPPORTING
LETTER (IF APPLICABLE).
I am aware that I have one or more exceptions or concerns among those listed below. I have checked all below
that apply. I have attached a SUPPORTING LETTER that: a) describes the circumstance for each exception, b)
presents a plan for addressing each exception, AND c) describes the option(s) that I am requesting the BSSW
faculty consider.
CURRICULUM EXCEPTIONS:
____ One or more required General Education courses and/or Social Work courses will not be completed by the
end of the current semester.
____ A grade of less than a ‘C-’ was received in one or more required Social Work courses.
____ SOWK 312/315 has not been completed with a grade of ‘P.’ (Students who will be completing SOWK 315
by the end of the semester before the semester in which they enroll in SOWK 441 do not need to request an
exception.)
COURSE PLAN EXCEPTIONS:
____ One or both GPA(s) are lower than 2.8 (Cumulative GPA and/or Social Work GPA)
____ My earned credits at end of the current semester is fewer than 75 credit hours.
____ My course workload is high for one or more semesters/summer sessions. (NOTE: If you plan to take more
than 16 credits in any semester and/or more than 8 credits during summer sessions, discuss why this is
necessary).
NOTICE OF PROFESSIONAL CONCERNS (NOTE: THESE CONCERNS SHOULD BE DISCUSSED WITH ADVISOR,
AND MAY BE ADDRESSED IN ESSAYS)
____ I am aware of problems with my oral and/or written communication skills and/or concerns about my academic
behaviors and performance and/or my professional behaviors and attitudes.
____ I have a past legal history that may affect my ability to find a placement for my senior practicum or finding
social work employment.
____ I have minimal or no human/social service, volunteer experiences, or community involvement history and/or
minimal to no experiences with diversity, social justice or advocacy activities.
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ACADEMIC AND CURRICULUM READINESS
Check the options below that apply.
All Applicants must submit a copy of their DARS Run as a Social Work Major
_____ I have submitted a copy of my DARS run as a Social Work major with this application. It has been
reviewed by Advising U staff from the College of Social & Behavioral Sciences as evidenced by the
cover sheet SIGNED by ADVISING U staff attached to the DARS.
Additional Academic Information
_____ My DARS run as a social work major and/or my current transcript presents a clear record of the required
courses I have completed for the BSSW program and I do not need to list previous schools attended.
_____ My DARS run as a social work major does not clearly list the required courses I have completed and I am
attaching copies of substitute/waiver forms and/or copies of transcripts from prior academic institutions
which are listed below.
COLLEGE
CITY, STATE
DATES
MAJOR
DEGREE/CERTIFICATE
ADD MORE ROWS TO THE ABOVE TABLE IF NEEDED.
Social Work 312/315 Junior Field Experience or equivalent
___
I completed SOWK 315 (or SOWK 312) at MSU, Mankato with a ‘Pass’ in (sem/year)__________ at the
agency listed below.
___
I am substituting another Field Experience course (number/name) ______________________, completed
in (sem/year) ____________ at (Name of Institution)____________________, at the agency listed below. This
course was substituted by a BSSW faculty advisor which is indicated clearly on my Social Work DARS. (NOTE:
If not clearly indicated on my DARS, attach a copy of the substitute form completed by BSSW Program Faculty
Advisor.)
____ I will complete SOWK 315 this current semester at the agency listed below.
_____ I will complete SOWK 315 this next summer semester at the agency listed below.
NOTE: Applicants MUST submit an evaluation form or letter evaluating performance in Field Experience
taken at MSU Mankato or at another institution before they will get permission to register for courses after
accepted to the major.
Field Experience Information
Agency:
Dates:
Supervisor at Agency:
Address/Email/Phone contact:
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COURSE PLAN--CURRENT AND FUTURE COURSES
Student Name:
Tech Id:
Second Major:
Minor:
Grade Point Average (GPA): For detailed instructions on how to find and/or compute your cumulative GPA (also
referred to as Overall GPA) and Social Work GPA, please see the application instruction packet and the ‘How to Compute
your GPA’ worksheets which are on the BSSW Program webpage.
All Students - Social Work GPA:
Transfer Students - Transfer GPA:
Cumulative/Overall GPA:
MSUM GPA:
Catalog/Bulletin Yr: ___ 2015/16 ___2014/15 ___2013/14 ___ 2012/13 __ 2011/12
CURRENT (THE SEMESTER YOU ARE APPLYING) SEMESTER/YEAR:
/
TOTAL CREDITS COMPLETED TO DATE =
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
+ Number of Credits Taken THIS Semester = Total Number Cumulative Credits +
__Other:
Credit Hours
# Credit Hours
=
NEXT SEMESTER/YEAR: __________/__________
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
+ Number of Credits Taken THIS Semester = Total Number Cumulative Credits +
# Credit Hours
=
NEXT SEMESTER & YEAR:
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
+ Number of Credits Taken THIS Semester = Total Number Cumulative Credits +
# Credit Hours
=
NEXT SEMESTER & YEAR:
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
+ Number of Credits Taken THIS Semester = Total Number Cumulative Credits
# Credit Hours
+
=
NOTE: TOTAL MUST ADD TO 120 credits for Catalog/Bulletin Years after 2010/11
OR to 128 credits for Catalog/Bulletin Years prior to 2010.
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MSU, MANKATO DEPARTMENT OF SOCIAL WORK
BSSW ACADEMIC AND PROFESSIONAL RESPONSIBILITIES CONTRACT
NOTE: Keep this document and following page for your records; Submit signature page at end.
A. IN ORDER TO GRADUATE WITH A BSSW FROM THE MSU, M DEPARTMENT OF SOCIAL WORK,
A STUDENT MUST:
 Be admitted to BSSW program and remain in “good standing” in the BSSW program. The definition of “good
standing” incorporates the student’s GPA and grade of a C- or better in all social work practice sequence and
upper division courses in order to be allowed to register and complete each successive practice course.
 The student must follow all policies as outlined in the MSU Student Handbook, The Right Stuff; the BSSW
Handbook, NASW Code of Ethics and Minnesota Statute 148E. Any violations may result in disciplinary
actions by the BSSW Program, which can range from a written warning to dismissal from the program to a
referral for University disciplinary action.
 Complete background checks at entry into SOWK 315 (SOWK 312) Junior Field and SOWK 450/455 Senior
Seminar and Practicum.
 Complete an Application to Practicum for permission to enter the SOWK 450/455 Senior Seminar and
Practicum.
 Successfully complete SOWK 455, Senior Practicum, of 440 hours in a social service agency during their
final semester. Agencies may have particular requirements or may require additional information from
students to assure the safety of clients, the confidentiality of services, and the absence of conflicts with agency
programs and policies. Students are expected to comply with agency requests that do not infringe on their
individual rights.
B. ACCOMMODATIONS FOR DISABILITIES
The Americans with Disabilities Act (ADA) requires that the University provide reasonable accommodations
for persons with disabilities. Students with a disability should contact the Office of Accessibility Resources
(ML 132) early in the program and in each semester to discuss their needs and develop an accommodation
plan. In addition, it is advisable, but not required, to inform instructors of your disability and how it may
impact your education. This applies to classroom courses as well as field education courses. The instructor
will make the necessary accommodations based upon the direction of the Office of Accessibility Resources.
C. ACADEMIC READINESS AND PROFESSIONAL BEHAVIOR AND ATTITUDES
Applicants to the social work program should be committed to developing and enhancing their academic
skills and professional behaviors and attitudes in all learning and fieldwork environments including a
commitment to developing good written and oral communication skills. Academic and professional behaviors
and attitudes that are not consistent with the University Student Handbook, The Basic Stuff, Department and
BSSW Program policies and procedures, or National Association of Social Work’s (NASW) Code of Ethics
or Minnesota State standards of practice may impact a student’s standing in the social work program.
Read the following documents on these sites for additional detail about student rights and responsibilities.
You are required to sign that you have done so and that you understand the implications of these rights
and responsibilities.
 BSSW Student Handbook:
http://sbs.mnsu.edu/socialwork/undergraduate/studenthandbook.html
 MSU, Mankato’s Student Handbook, The Basic Stuff:
http://www.mnsu.edu/students/basicstuff/
Read the following documents on these sites for additional detail about the ethics and responsibilities of the
social work profession. You are required to sign at the end of this document that you have done so and that
you understand the implications of these codes of ethics in your professional responsibilities.
 Minnesota Board of Social Work URL: http://www.socialwork.state.mn.us
 Minnesota Statutes, Chapter 148E, Social Work Practice: https://www.revisor.mn.gov/statutes/?id=148E
 National Association of Social Work Code of Ethics: http://www.socialworkers.org/pubs/code/code.asp
 International Federation of Social Workers Code of Ethics: http://www.ifsw.org/f38000032.html
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D. PROFESSIONAL BEHAVIORS AND ATTITUDES AND THEIR IMPACT ON SOCIAL WORK LICENSING AND
EMPLOYMENT
Social workers and students in social work programs are expected to demonstrate high standards of academic,
professional and personal behavior and attitudes. Your first obligation is to clients. A social worker’s
academic, personal and/or professional behaviors or attitudes must not be allowed to interfere with or impair
service to clients.
E. BARRIERS TO PROFESSIONAL SERVICE
Students admitted to the social work program must assume responsibility for recognizing and removing
academic, personal, and professional barriers that may impact their success during coursework or may limit
their ability to serve clients either during fieldwork, or future employment. Difficulty with written and oral
communication skills should be addressed prior to graduation. Other personal or professional behaviors that
impact a student’s ability to function as a social worker should be recognized and responded to also. For
example, chemical dependency, poor physical or mental health, emotional problems, and/or severe unrelieved
stress may impair service to clients and should be identified and addressed throughout one’s academic and
professional career.
F. BACKGROUND CHECKS AND LEGAL RECORDS AND CRIMINAL AND OTHER TYPE OF
CONVICTIONS
Because social workers work with many vulnerable populations, security background checks are required for
MSUM Department of Social Work students when students apply to their fieldwork courses, SOWK 315
(formerly SOWK 312), Junior Field, and SOWK 455. Senior Practicum. In addition, background checks are
often required for employment in human service fields.
Students should be aware that a history of past legal problems may negatively affect internship and
employment opportunities. For example, driving offenses, substantiated complaints of maltreatment against
children and vulnerable adults, convictions related to substance use/abuse may not only significantly limit
internship/practicum and employment opportunities, but may also keep students from successfully completing
the social work program or finding employment after graduation. Previous termination from volunteer,
internship, or paid positions because of sexual abuse or sexual harassment can also significantly limit
fieldwork and employment opportunities. Students with past criminal conviction(s), active, or pending
criminal case(s) should consult with their advisors and discuss the implications for required fieldwork and
future employment.
Criminal convictions are also reviewed when application is made for social work licensure in Minnesota. A
conviction of a felony, gross misdemeanor, and some misdemeanors may keep graduates from being licensed
and significantly limit employment options. Applicants with a history of violence, sexual harassment, or
chemical dependency should have successfully completed treatment and resolved any legal concerns prior to
search for employment as a social work professional.
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Minnesota State University, Mankato
DEPARTMENT OF SOCIAL WORK
BSSW ACADEMIC AND PROFESSIONAL BEHAVIORS
RESPONSIBILIITES CONTRACT
PLEASE READ, SIGN, AND SUBMIT WITH YOUR BSSW PROGRAM APPLICATION.
I have read and agree to abide by the guidelines as outlined in this document.
I have read the Minnesota State Mankato Department of Social Work BSSW Student Handbook and the
MSU, Mankato’s Student Handbook, The Basic Stuff.
I have reviewed the Minnesota Board of Social Work Statutes and Practice Act,148E and the NASW
Code of Ethics, and the International Social Work Code of Ethics.
I understand I am assuming professional obligations and attest that I will study and practice social
work within the ethical boundaries of the profession. I expect to use my education to promote social
justice, strengthen human relationships, uphold the dignity and worth of all people, and practice with
the utmost of integrity.
I have read the information above about limitations to social work licensing and employment and my
responsibility for addressing any academic concerns, personal and professional behaviors and attitudes,
and/or legal/other impairment which may impact my ability to competently perform my duties as a
social work student and/or as a future social work professional.
Further, I understand that failure to meet one or more of the conditions described in the contract above
can negatively impact my student status as ‘a student in good standing’ in the MSUM Department of
Social Work’ which may result in the inability to graduate from the social work program. I understand
that violations of program, institutional, and professional practice and policies can result in disciplinary
action.
Print Name:
Applicant Signature
Date
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