BSSW APPLICATION COVER SHEET
IDENTIFYING INFORMATION
NAME
LAST
TECH ID
FIRST
MIDDLE
Place a checkmark “” in the box by either the ‘Local Address’ or ‘Permanent Address’ to let the Social Work 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
(
)
LOCAL
|(
ZIP
)
PERMANENT
|(
)
CELL
MAVMAIL ADDRESS:
Faculty will primarily communicate with you using your Mavmail email address.
Please check your Mavmail account routinely.
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. I UNDERSTAND THAT AN INCOMPLETE APPLICATION MAY
RESULT IN MY APPLICATION NOT BEING REVIEWED IN A TIMELY MANNER.
________________________________________________________________________
STUDENT SIGNATURE
|
DATE
PRINT STUDENT NAME: _______________________________________________________
I HAVE MET WITH THE STUDENT APPLICANT AND REVIEWED THE BSSW PROGRAM APPLICATION.
_________________________________________________________________________
ADVISOR SIGNATURE
|
DATE
PRINT ADVISOR NAME: _______________________________________________________
I, (student 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 BSSW Program Application and
have included the following documents in this application packet.
_____ The BSSW Program application SIGNED and DATED by student applicant and BSSW faculty advisor.
_____ I have elected to submit my resume in lieu of the resume in the application.
_____ Request for Exception form and supporting letter (if indicated).
_____ Minnesota State Mankato 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).
_____ A SIGNED and DATED BSSW Program Academic and Professional Behaviors Statement of Responsibilities
Contract. (Please keep page 6 &7 for your records).
_____ 3 essays.
_____ 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 am aware of other academic or professional concerns in my
BSSW Program application that may impact the BSSW Program’s application decision-making process.
_____ I have checked all exceptions below that apply and am attaching a letter that
1. Describes the circumstance for each exception,
2. Presents a plan for addressing each exception, AND
3. Describes the option(s) that I am requesting the BSSW faculty consider.
CURRICULUM EXCEPTIONS
_____ One or more General Education required courses, foundation, introductory, or integrative 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 Social Work foundation, introductory, integrative,
and/or advanced course(s).
_____ SOWK 312/315 was not satisfactorily 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 or _______Social Work GPA
_____ My course credit at end of the current semester is less than 75 credit hours. #________
_____ My course workload is high for one or more semesters/summer sessions. (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 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.
BSSW Program Application. Revised 2015.
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RESUME
PUBLIC, PRIVATE, NONPROFIT, OR TRIBAL HUMAN/SOCIAL SERVICES EMPLOYMENT
_______________________________________________________________________
Name & location (city, state)
|
Number of hours, date(s), month(s), year(s)
Describe responsibilities:
_______________________________________________________________________
Name & location (city, state)
|
Number of hours, date(s), month(s), year(s)
Describe responsibilities:
PUBLIC, PRIVATE, NONPROFIT, OR TRIBAL HUMAN/SOCIAL SERVICES VOLUNTEER EXPERIENCES
_______________________________________________________________________
Name & location (city, state)
|
# of hours, date(s), month(s), year(s)
Describe responsibilities:
_______________________________________________________________________
Name & location (city, state)
|
# of hours, date(s), month(s), year(s)
Describe responsibilities:
MEMBERSHIP IN ACADEMIC, PROFESSIONAL, OR COMMUNITY ORGANIZATIONS
_______________________________________________________________________
Name & location (city, state)
| Dates involved
_______________________________________________________________________
Name & location (city, state)
|
Dates involved
ACADEMIC OR SOCIAL WORK RELATED WORKSHOPS, TRAININGS OR EVENTS ATTENDED
_______________________________________________________________________
Name & location (city, state)
| Dates involved
_______________________________________________________________________
Name & location (city, state)
| Dates involved
For the experiences listed above, identify below if you had the opportunity to interact with diverse communities,
engage in leadership activities, gain experience in rural or global communities, or engage in advocacy and social
justice activities.
List academic or professional experiences, skills, languages, or strengths that you believe will contribute to
your success as a social work student and future professional.
NOTES:
EXPAND ANY SECTION AS NEEDED. YOU MAY ALSO DISCUSS RESPONSES ABOVE IN THE ESSAYS.
YOU MAY SUBMIT A FORMAL RESUME IN LIEU OF THE ABOVE RESUME. PLEASE MAKE SURE THE CATEGORIES
ABOVE ARE ADDRESSED.
BSSW Program Application. Revised 2015.
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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 .
COLLEGE
CITY, STATE
DATES
MAJOR
DEGREE/CERTIFICATE
ADD MORE ROWS TO THE ABOVE TABLE IF NEEDED.
Social Work 315: Junior Field Experience --Place a checkmark “” next to the option that describes your
SOWK 315 status. All students must complete this section even if you completed SOWK 312 or substituted a similar
junior field course from another school.
SOWK 312/315 Completed:
_____ I completed SOWK 315 (or SOWK 312) at MSU, Mankato in (semester/year)_________.
______ I am substituting a Junior Field Experience course which I completed in (semester/year) ______________ at
(Name of Institution)____________________ AND this course was substituted by a MSU, M 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.)
Select from the following options:
_____ I completed this course with a grade of ‘P’.
_____ I did not earn a grade of ‘P’ in SOWK 315 (or equivalent junior field course). I have attached a letter
explaining this request for an exception. (see page 2 of this application for more information re: requesting
exceptions).
SOWK 312/315 is not yet completed:
_____I will complete SOWK 315 this semester. _____ I will complete SOWK 315 (Semester/Year) _____________
Agency: _______________________________
City:_____________________________________
Supervisor: ____________________________ Expected Completion Dates:__________________
BSSW Program Application. Revised 2015.
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COURSE PLAN--CURRENT AND FUTURE COURSES
Student Name________________________________
Second Major _____________________________
Tech Id: _______________
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:
Transfer Students:
Social Work GPA: ________
Cumulative/Overall GPA: __________
Transfer GPA: ________
MSUM GPA:___________
Select Catalog/bulletin year:
_____ 2015/16 ____ 2014/15
____2013/14 _____ 2012/13
____ 2011/12
_____Other
Credit Hours Earned PRIOR to current semester:
____________
CURRENT (THE SEMESTER YOU ARE APPLYING) SEMESTER/YEAR: __________/__________
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
# Credit Hours
Number of Credits Taken THIS Semester // Total Number Cumulative Credits
//
NEXT SEMESTER/YEAR: __________/__________
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
# Credit Hours
Number of Credits Taken THIS Semester // Total Number Cumulative Credits
//
NEXT SEMESTER/YEAR: __________/__________
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
Number of Credits Taken THIS Semester
# Credit Hours
// Total Number Cumulative Credits
//
NEXT SEMESTER/YEAR: __________/__________
Course #
Course Name (Indicate if Gen Ed Category/Minor/other Major)
Number of Credits Taken THIS Semester
# Credit Hours
//*Total Number Cumulative Credits
//
Cat/Bull.-- 2010-2011/earlier >/=128 credits; 2011-2012/present >/=120 credits.
Add boxes/page if needed.
BSSW Program Application. Revised 2015.
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MSU, MANKATO DEPARTMENT OF SOCIAL WORK
BSSW ACADEMIC AND PROFESSIONAL RESPONSIBILITIES CONTRACT
A. IN ORDER TO GRADUATE WITH A BSSW DEGREE 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, 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 or University disciplinary action. If a student is suspended or dismissed
from the BSSW Program then the student will have to apply for re-admission.
 Complete background checks at entry into SOWK 315 (old SOWK 312) Junior Field and SOWK 450/455,
Senior Practicum.
 Complete an Application to Practicum for permission to enter the SOWK 450 Senior Seminar and SOWK
455 Senior 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.
For additional detail about student rights and responsibilities, read the information on the following
Department and Institutional websites. You are required to sign at the end of this document 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/
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For additional detail about the ethics and responsibilities of the profession, you are asked to read
information on the following websites. 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 State Statutes 2012, Chapter 148E, Board of Social Work Practice: http://bit.ly/1Hw6glT (the
bitly.com address is a direct link to the Minnesota Government website)
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
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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MSU, 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.
Student Signature
/
Date
NOTE: PLEASE KEEP PAGES 6 & 7 FOR YOUR RECORDS.
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