BSW Senior application form All students entering Practicum will be required to attend an Orientation prior to the beginning of the semester; dates to follow. Part I: General InformationName* First Last Pronouns Temple University Email (tu------@temple.edu)* TUID Number (This number should be a 9-digit value found on your student ID)* Phone*List your expected address at the time of your internship* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If your address changes prior to the start of your field practicum please notify the field office as soon as possible.Program StatusHave you submitted your Senior Eligibility Paperwork to Canvas and been approved? Yes No If no, please work with your BSW advisor to receive confirmation that you have been approved for senior eligibility.Program* Onsite BSW Program Online BSW Program Choose program format (when will you complete your practicum)* Fall/Spring 2024-25 Fall/Spring 2025-26 Are you an international student?* Yes No List any languages in which you are fluent other than English* Have you (or will you) apply to the Child Welfare Education for Baccalaureates (CWEB) program?* Yes No CWEB Program: Its goal is to strengthen public child welfare services in Pennsylvania by providing educational opportunities for undergraduate social work majors preparing for employment in one of Pennsylvania's 67 public child welfare agencies. Qualified persons who are full time social work majors in their senior year at any of the approved schools (Temple University is approved) may receive an educational fellowship in return for a contractual obligation to accept employment in a Pennsylvania public child welfare agency immediately following their studies. **Please speak with your BSW advisor and the Office of Practicum Education if you are interested.Disability Resources ServicesIf you are in need of an accommodation, please make an appointment with a coordinator in the Disability Resources and Services Department. DRS will collaborate with you and the Office of Practicum Education to coordinate necessary access and accommodations in these types of field experiences. Once you are assigned to a staff member in the Office of Practicum Education, please contact them as well as your DRS coordinator in order to begin planning for an accessible experience.Will you submit an accommodation letter provided by the Disability Resources Services for your Practicum course/Agency experience?* Yes No TransportationAre there any transportation concerns that affect where you can be placed?* Do you have a driver's license?* Yes No Do you have access to a car?* Yes No Availability for FieldChoose the schedule that you intend to follow* 2 Full days Evening/Weekend hours only (You MUST complete the Self-Referral Form) Placement OptionsPick one option below for the placement process to start. ONSITE PROGRAM students: have 3 placement options: Field Department Referral, Student Self-Referral, or Employment-based Proposal. FULLY ONLINE PROGRAM students: have 2 placement options: Student Self-Referral or Employment-based Proposal.Field Department Placement Option (Onsite Program Students ONLY)A Field Education Specialist will be assigned to locate a placement for your upcoming year based on the application. Student must have 2 full days available during the weekday to be eligible for this option.A. Field Department Placement Option* Yes No Student must 2 full days during the weekday (Monday-Friday) to be eligible for this option Category A (Setting) *Please list up to 3 specific agencies (or types of settings) that best represent your desires for field placement. Category B (Population) *Please check one option that best represents your desires for field placement.AnyChildrenYoung AdultsElderlyOtherEmployment-Based option (Onsite or Online Program Students Option)For students who would like to complete a field placement at their place of employment, the Employment Based-Proposal will also be required.B. Employment-Based Field Placement* Yes No Office of Practicum Education will confirm appropriateness of placement once employment based proposal is turned into the office.*Indicate the date you will submit the Employment-Based Proposal MM slash DD slash YYYY Student Self-referral Option (Onsite or Online Program Student Option)A student can independently contact an agency to solicit their own field placement including making inquiries to determine if an agency is interested in a student intern. Students who want to intern at a specific agency or who only have evening/weekend availability are required to complete a Self-Referral. The student will be partnered with a staff member from the Office of Practicum Education to discuss the individual plan further. The Self-Referral Form, completed in addition to this main practicum application, will be due before this plan can be confirmed.C. Student Self-Referral* Yes No Do you have a personal history or experience that may affect you or the population you work with?* Yes No Is there anything you wish to add to your application as a consideration in your placement process?*Part II: ClearancesPart II: Obtaining clearances* The Office of Practicum Education mandates that all students obtain the maximum clearances required by the state in which the practicum is located, as outlined by CastleBranch system. Each individual agency may request additional clearances for their specific site. You must communicate with your agency directly for guidance around additional clearances required. Obtaining clearances are required for all students going into field practicum courses, including Employment-based students. By initialing here, I acknowledge I am aware that if I do not obtain my own set of clearances prior to the start of my practicum, I will be dropped from the course and pulled from practicum.Part III: Professional Resume(typed or word processed, no more than 3 pages) Professional Resume*Max. file size: 15 MB.Part IV: EssayCompose an essay - between 500-600 words that provides a summary of your interests for your social work education.Essay*Max. file size: 15 MB.SignatureStudent Signature* I understand that the Office of Practicum Education and the agencies that accept students for placement work closely together to provide me with an opportunity to meet the learning objectives of the courses in which I enroll and then to evaluate my progress toward meeting them. To this end, instructors, faculty and practicum education staff may share information about my written and verbal communication and performance in the placement site. I realize that it is my responsibility to inform the Office of Practicum Education if I have any reason to believe that a particular placement site is a potential conflict of interest for me.