Office of Field Instruction

Office of Field Education National Catholic School of Social Service The Catholic University of America Cardinal Station, Washington, DC 20064 Phone: 202-319-5457

FIELD INTERNSHIP APPLICATION Foundation Year MSW Field Internship

Date ______CUA ID# ______Name ______D.O.B.______Permanent Street Address______City______State______Zip Code ______Phone (home) ______(cell) ______(work) ______Email (please print) ______Anticipated Local/School Address (if different from above) ______City ______State ______Zip Code ______Summer address, if different from above ______Anticipated re-location date (if applicable) ______

Student status in upcoming academic year. Check all that apply: ___ Full-time ___ Part-time ___ Dual degree JD/MSW student Personal information: Undergrad college ______Major: ______Yr of Grad: ______Grad college (if applicable) ______Major: ______Yr of Grad: ______ Do you have a driver’s license?__ Yes __ No  Do you drive an automobile? __ Yes __ No

. Will you have a car to get to and from field agency? __ Yes __ No . If you will have a car, are you willing to use your car to transport clients? __ Yes __ No Our policy prohibits students from driving their own vehicles to transport agency clients unless they voluntarily elect to transport clients in their vehicles in order to be placed in a particular agency/kind of agency. If this will be a requirement, it should be discussed and agreed upon at the placement interview.  Do you speak another language? __ Yes __ No

If yes, do you wish to utilize this language in field agency, if possible? __ Yes __ No If yes, indicate language and level of proficiency: ______

 If you are a Part-time student, are you requesting a flex-time placement (i.e. a combination of day/evening/weekend hours)? __ Yes __ No.

 Insurance Coverage (mandatory information): Will you be covered by the CUA Student Health Plan? __ Yes __ No. If no, provide name and address of provider, & policy #: ______Your responses below are for internal Office of Field Education use only:

A. Are you applying for federal work study funding? This funding is awarded based on financial need (as determined by the FAFSA) for work completed as part of a student’s field internship; no extra work hours are required. __ Yes __ No. If Yes, next year you must (1) show financial need; (2) submit the FAFSA as early as possible, (3) be placed at a non-profit agency, and (4) be a full-time student. This funding is extremely limited.

If interested in being considered for this funding, please indicate how many credits you plan to register for: fall semester: ______spring semester: _____.

B. Age Group(s) in which you are most interested (Number in order of preference):

 Elderly  Adults (other than elderly)  Children  Adolescents  Families (in 1st year, family work most available in protective services, requiring home visits)  Any or all

C. Kinds of social services in which you are most interested (number in order of preference - up to 4):

 Child welfare  Homeless  Legal/Criminal Justice  Developmentally disabled  Health/Medical  Psychiatrically disabled (chronically mentally  Elderly ill)  At-risk families  Schools/Special Education  Immigrant populations  Military/Veterans  Other ______

D. If you will be away for any extended period between now and the beginning of the fall semester, please indicate dates when you will be away below. If you currently live out of the area, please indicate what your availability for interviewing with a prospective agency will be AND indicate where you anticipate living (e.g. Silver Spring, MD, Washington, DC).

1/9/2018 2 E. After searching for possible Foundation Year Field agencies using the Field Education Search Engine, please indicate which agencies you have an interested in the space below.

Please respond to the following questions. These statements, your resume, and the first page of this application will be shared with the field agency:

1. Please provide a brief statement of your social work interests and field internship learning goals.

2. Please describe the ways you will be of service to clients, the field agency, and the social work profession.

1/9/2018 3 If you have a documented disability for which you would like to request reasonable accommodations in your field agency, you must identify yourself to the CUA Office of Disability Support Services (DSS), (202-319-5211) and notify them that you will be applying for a field internship. Once your disability is verified and you have been approved for services through DSS, you must then speak with the Director of Field Education if you wish to request accommodations in your field placement. It will greatly assist the Director of Field Education in referring you to the most appropriate field placement to have knowledge about reasonable accommodations that have been determined by DSS for you before referring you for an interview.

Feel free to provide information which will be helpful below:

______

F. Please provide contact information for an individual whom we may call in the event of an emergency at your internship site.

Please print:

Name: ______

Relationship: ______

Phone: (cell): ______(work): ______

(home): ______

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