The School of Social and Behavioral Sciences
MSW Student Field Placement Application
All fields required unless noted as optional.
  Full Name:    
  Address:
     
  City, State ZIP:  ,        
  Home Phone: Cell: Work:
  E-mail:
  Emergency Contact Information (optional)
  Full Name:    
  Address:
     
  City, State ZIP:  ,        
  Home Phone: Cell: Work:
  E-mail:
 
  Strengths
  (Briefly state the skills or experience you believe you possess)
  Learning Needs
  (Briefly state the challenges you have and skills you want to acquire)
 
  General Information
  Information provided will not preclude a placement, but may place a limit on specific types of placements available
  1. Do you speak a language other than English? Yes:      No:  
      If Yes please specify:  
  Note: In some instances, students cannot do their field placement where they work or for "for-profit agencies" if they are receiving federal work study financial assistance.
  2. Do you plan to drive to field?   Yes:      No:  
      If no, how do you plan to get to field?  
  3. Have you ever been convicted of a crime? Yes:      No:  
  4. Have you ever been investigated for child abuse or neglect?
      Yes:      No:  
  Students with a disability are encouraged to disclose that disability if accommodations are requested on this application form. Such disclosure permits the field agency and the field coordinator to make sure you are placed in an environment that enhances your learning opportunities.
  5. Are you a student with a disability that has been reported to Stockton University's Learning Access Center and requires accommodation?
      Yes:      No:  
  What type(s) of accommodation is requested?
 
  6. Are there any agencies or client populations with which you cannot be placed (e.g. you were once a client who received services or you or a family member are currently receiving services from an agency, you were fired from a job with an agency, etc.). Please specify them below and why this is so:
 
  7. Internships are typically served during normal business days and hours, Monday-Friday, 8am to 5pm. Are you available to complete your placement during normal business hours?
      Yes:      No:   **
      ** If you have selected No, please indicate your availability below:
 
Mon. to       Tues. to       Wed. to
Thu. to   Fri. to   Sat. to
Sun. to                    
 
  Preference Checklist
Review the list of social work fields of practice (underlined) and the types of organization under each field. Please select from 1 (first choice) to 5 (fifth choice) ranking your preferences. Choose only a total of five for fields of practice and three for geographic areas.
  Accepted Into:      
  1st Year of 2-Year Program Advanced Standing Program MCWEP
  2nd Year of 2-Year Program
  Fields of Practice
Please select from 1 (first choice) to 5 (fifth choice) ranking your preferences.
  1. 2.  
  3. 4.  
  5.
    If Other please specify:  
  Geographic Areas Preferred
  Atlantic County Cape May County Cumberland County
  Ocean County Gloucester County Burlington County
  Mercer County Camden County    
 
  CONSENT FOR RELEASE AND/OR EXCHANGE OF STUDENT INFORMATION
  I hereby authorize Stockton University, Social Work Program, Coordinator of Field, and faculty to share pertinent personal information particularly criminal background, felony convictions, physical health, mental health, and/or disability status for the purpose of securing and/or maintaining an internship that meets Social Work Program standards with field agency representatives and field instructors as appropriate.

I understand that this information will be used solely for the purpose noted above and to fulfill my own educational needs to achieve professional competencies. This consent is in effect for the duration of my admission to the Social Work Program unless revoked in writing. I hereby hold harmless the Coordinator of Field, faculty, and Stockton University from and against any and all claims resulting from the release and/or exchange of information about me during or after the completion of my academic program.
  I consent to the release and/or exchange of personal information as noted above.