PRACTICUM APPLICATION

DANA COLLEGE
FIELD PRACTICUM APPLICATION

Name ___________________________________ Date ________________________

Home Address __________________________________________________________

School Phone ____________________ Home Phone __________________

Do you wish to begin the practicum sequence? Yes (Circle)

Semester and year you wish to begin _____________________

Do you have your own car? Yes________ No_______

Do you have any special physical needs related to the practicum (e.g., wheelchair ramps, elevators, other special equipment or arrangements)?

Please describe: ________________________________________________________

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Agency where you spent SW 215 field experience __________________________

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Previous professional experience ________________________________________

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Which social work fields of practice interest you most? _________________

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List any agencies in which you have a particular interest: ______________

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Have you applied for professional liability insurance? Yes____No____


Have you joined NASW? Yes____ No____

Signature __________________________

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