DUE DATE:
April 17, 2015
UNIVERSITY AT ALBANY
SCHOOL OF SOCIAL WELFARE
Application - 1st Field Placement
INSTRUCTIONS: Please complete and return this application with one copy of an up-todate resume to the Field Education Office, Richardson 116.
NAME:
LOCAL ADDRESS & PHONE NUMBER:
(
)
SUMMER ADDRESS (IF DIFFERENT FROM ABOVE) AND PHONE NUMBER:
(
)
FOR OFFICE USE ONLY
COs:______________________________________________ LIC/CAR DRC:_____
AGENCY ASSIGNED ___________________________________________________
PROG/UN IT
________________________________________________________
INSTRUCTOR ________________________________________________________
COMMENTS
________________________________________________________
______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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1st Field Placement
FIELD PRACTICUM APPLICATION
Please list your most recent position in human services (if none, your most recent work or
volunteer experience):
Dates of Service
Name of Organization
Position Title
Supervisor’s Name
Tell us briefly what you did/learned in this work/volunteer experience:
Please list your strengths and areas for improvement identified during the work/volunteer
experience identified above:
Please describe your previous experience with supervision:
Do you speak a language other than English?
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☐ NO
☐ YES Click here to enter text.
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FIELD PRACTICUM APPLICATION
1st Field Placement
Disabilities:
Reasonable accommodations will be provided for students with a documented disability. Any
disability that requires an accommodation in field requires a formal request for accommodation
be made to the University at Albany’s Disabilities Resource Center in Campus Center-137 or
(518) 442-5490 as soon as possible. Thereafter, the Field Office will work with students and
field agencies in an effort to provide such accommodations. Below, please indicate if you will
be requesting an accommodation in field as a result of reported disability that has been filed with
the University at Albany’s Disabilities Resource Center. If not indicated, please write “N/A”.
Anything else that you hope might be considered in developing your placement, if possible?
Information related to placement Location:
(If your answer is “no” to any of the following questions, please understand that your options may be
limited)
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Do you have a current driver’s license?
☐ YES
☐ NO
Do you have a car available to travel to and from field?
☐ YES
☐ NO
Some agencies expect students to have a car available for
travel related to the placement (not client transport).
Can you meet this expectation?
☐ YES
☐ NO
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NOTE: The School’s policy states that you may be placed in an agency that is located within a
100 mile radius of Albany or your home community. However, every effort will be made to
accommodate preferences where possible.
PLEASE INDICATE IN WHICH COUNTIES YOU WOULD PREFER TO BE
PLACED:
North Country
☐ Clinton
☐ Essex
☐ Warren
☐ Washington
☐ Hamilton
☐ St. Lawrence
☐ Franklin
Central NY
☐ Broome
☐ Chenango
☐ Cortland
☐ Delaware
☐ Oneida
☐ Tioga
☐ Tompkins
☐ Otsego
☐ Onondaga
Capital District
☐ Albany
☐ Columbia
☐ Fulton
☐ Montgomery
☐ Rensselaer
☐ Saratoga
☐ Schenectady
☐ Greene
☐ Schoharie
Southern NY
☐ Dutchess
☐ Ulster
☐ Orange
☐ Putnam
☐ Sullivan
Vermont
☐ Addison
☐ Rutland
☐ Bennington
Massachusetts
☐ Berkshire
☐ Hampshire
Connecticut
☐
☐ I have attached one copy of my updated resume.
☐ I have read the “Required Reading - 1st Field Placement”
By signing below, I assert that I am aware of the SSW Standards for Social Work Education. I
understand that any information deemed important to the placement will be shared with the field
instructor. If required for my placement, I agree to complete a criminal background check, child abuse
registry and/or any health screenings (including drug testing, TB and Hepatitis-B test, etc.) necessary for
the acceptance of my field placement. By declining an agency’s request for these required procedures, I
am aware that my refusal will limit my placement options or lead to me not obtaining a field placement. I
understand that a classification as a sexual offender will deem me ineligible for field.
Student Name
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Date
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