Adrian College Social Work Program Application for Field Placement Date of Application Full Name Permanent Address Home Telephone Cell Phone Business Phone Summer Phone Email Social Work Advisor Required social work courses completed by the end of the current semester Foundations of Social Work Social Welfare Policy Human Behavior in the Social Environment Generalist Social Work Practice Methods I generalist Social Work Practice Methods II Required courses and social work cognates completed by end of the semester Sociology and Social Problems General Psychology Social Research Methods Biology and Society American National Government or State and Local Government At least one of the following: Sociology of Sex and Gender Race and Ethnic Relations Diversity: Inequality, Privilege, and Oppression Explanation if missing a course, and when you are scheduled to take it: Criminal History Have you ever been convicted of a felony? No Yes If yes, please explain. Employment HistoryIf you have a resume, you may email it to socwprogram@adrian.edu instead of filling out the employment and volunteer history below. Complete the remaining items, however and sign it. Work experience, beginning with current or most recent employment Employer Type of business Address Telephone Dates of Employment Position and work description Full-time or Part-time? Full-time Part-time Employer 2 Type of Business 2 Address 2 Telephone Number 2 Dates of Employment 2 Position and Work description 2 Full time or Part time 2 Full-time Part-time Employer 3 Type of Business 3 Address 3 Telephone Number 3 Dates of Employment 3 Position and Work description 3 Full time or Part time 3 Full-time Part-time Volunteer Experience Agency or Organization Type of Service Full Address Phone Number Dates of Experience Position + Work description Approximate number of hours per week Agency or Organization 2 Type of Service 2 Full Address 2 Phone Number 2 Dates of Experience 2 Position + Work description 2 Approximate number of hours per week 2 Agency or Organization 3 Type of Service 3 Full Address 3 Phone Number 3 Dates of Experience 3 Position + Work description 3 Approximate number of hours per week 3 Other Skills Do you have language skills other than English? Yes No Language Proficiency Limited Advanced If English us not your primary language, please indicate proficiency in conversational English: English Proficiency Limited Advanced Do you possess a valid Driver's License Yes No Please indicate other special skills or training Placement Interests Your preferences will be noted in field placement assignments. Not all placements may Please list your career goals, areas of interest pertinent to field placement experience: Please list the agency or agencies in which you are particularly interested for your placement: Special Needs Please note special circumstances that warrant consideration in the placement matching process. Physical disabilities, health issues, personal or fami Student Signature Date