<p> Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861</p><p>APPLICATION UNIVERSITY CONSORTIUM FOR CHILDREN AND FAMILIES (UCCF) TITLE IV-E STIPEND PROGRAM</p><p>Directions: Entering full-time two-year clinical concentration MSW students are eligible to apply. Only students with completed MSW program applications will be considered for the stipend. Title IV-E stipend applications can be submitted concurrently with MSW Program applications. </p><p>Title IV-E Stipend applications must be postmarked by March 15, 2017. Only hard copies of the application will be accepted. Applications should be mailed to Virginia Olivas, MSW, UCCF Coordinator, Azusa Pacific University Master of Social Work Program, 901 East Alosta Avenue, P.O. Box 7000, Azusa, CA 91702</p><p>Date of Application: I. STUDENT INFORMATION:</p><p>Name: Student ID# </p><p>Local address: Date of birth: </p><p>City: State & Zip: Gender: Male Female</p><p>Permanent address (if different): Phone number: </p><p>City: State & Zip: Cell Phone: </p><p>If you plan to move, please give the approximate date and geographic location: </p><p>Email address: </p><p>Emergency contact & phone number: </p><p>Are you a U.S. Citizen? Yes No </p><p>If no, please answer the following: Visa type: Visa # Visa expiration date: Country of origin: </p><p>Driver’s license: </p><p>Auto license plate #: Insurance carrier: </p><p>II. LANGUAGE SKILLS (other than English)</p><p>Language(s) spoken Rate verbal & written fluency Can you conduct interviews & Can you write reports? on a scale of 1-5 assessments? 1=least fluent, 5=most fluent</p><p>Verbal: Written: Yes No Yes No</p><p>Verbal: Written: Yes No Yes No</p><p>UCCF Application 2017-18 F.Y. Rev 2-16-17 1 Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861</p><p>III. RELATED EXPERIENCE: List any previous child welfare-related work experiences, beginning with most recent, including name of agency, job title, and length of employment. (attach additional pages as needed).</p><p>Organization or Agency Address Phone: Start/End Dates Job Title</p><p>1. Duties/Responsibilities:</p><p>2. Duties/Responsibilities:</p><p>3. Duties/Responsibilities:</p><p>Important Information:  Eligible candidates must be accepted to the Clinical Practice with Individuals & Families Concentration in order to be eligible for the UCCF Title IV-E Stipend  Final Title IV-E Stipend awards are contingent upon final funding of Title IV-E stipend UCLA sub-award grant, anticipated July 1, 2017.  All prospective UCCF Title IV-E Stipend Program student interns will be required to pass L.A. County DCFS hiring standards, including, but not limited to, background checks, and psychological and medical examinations. </p><p>. Is there anything in your background that may prevent you from passing a security clearance? Yes No . Is there anything that might prevent you from driving (hiring standard) while at DCFS? Yes No</p><p>I understand that the UCCF Title IV-E Stipend award requires that I complete all of the following requirements (initial after each):</p><p>. Adhere to the NASW Code of Ethics ______. Maintain active enrollment in the APU MSW Program and remain in good academic standing with a B (3.0) average _____ . Be enrolled in the MSW Program in the Clinical Practice Concentration _____ . Maintain a driver's license, a working vehicle, and automobile insurance while enrolled in the MSW Program _____ . Be willing to utilize own vehicle during field internship ______. Successfully complete and receive a grade of B or higher in all field courses _____ . Successfully complete the MSW Program in the timeframe expected per cohort requirements (unless a hardship extension is granted by DCFS and the University in writing) _____ . Complete the required MSW and Specialized Child Welfare curriculum, including UCCF orientation _____ o SOCW 546 Family Therapy in Context _____ o SOCW 541 Capstone Leadership Project with focus on child welfare population, issue area, or service delivery system _____ o SOCW 537 Child & Adolescent Behavioral Health and Diagnosis_____ . Attend specialized training seminars _____ . Attend regularly scheduled UCCF meetings and activities _____ . Agree to flexible hours to attend UCCF learning opportunities (e.g., to attend a specific court hearing or to supervise a parent- child visitation for your assigned client) which may include hours outsider of your normal field internship schedule _____ . Fulfill a two-year work commitment in L.A. County DCFS immediately following graduation (attend first available DCFS Academy). ______. Failure to fulfill this requirement will result in personal payback of the stipend in the amount of $18,500 per year plus interest as applicable ______</p><p>UCCF Application 2017-18 F.Y. Rev 2-16-17 2 Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861</p><p>Policy Statement on Title IV-E Recipients </p><p>The Title IV-E Master of Social Work Training Program was created for social work students who are interested in a career in Child Welfare. The training itself has a Child Welfare competency-based curriculum. Students receive a stipend and commit themselves to two years of continuous employment in Los Angeles County Department of Children & Family Services after receiving their MSW degree. Students who participate in this program have made a special commitment to the field of child welfare.</p><p>Affirmation and Release of Information</p><p>I give the UCCF and DCFS selection committees permission to review my Application, Application Essay, and related materials for consideration to the UCCF field education program, Department of Social Work, MSW Program, Azusa Pacific University. I hereby attest that I have never been convicted of a felony crime or misdemeanor crime that would disqualify me from service in a county child welfare service agency, or any crime involving harm to children. I hereby attest that I have never been discharged from employment at a county or other social services agency due to violation of county code/merit system rules or violation of agency or professional ethics codes.</p><p>______Student Signature Date</p><p>______Student Name (printed)</p><p>UCCF Application 2017-18 F.Y. Rev 2-16-17 3 Department of Social Work Master of Social Work Program 901 E. Alosta Ave./P.O. Box 7000 Azusa, CA 91702-7000 PH: (626) 857-2401/ FAX: (626) 815-3861</p><p>UCCF PROGRAM APPLICATION QUESTIONS</p><p>Please respond to the following questions on a separate sheet of paper (your responses to the six questions, in total, should not exceed two typed pages) and submit them with your application</p><p>1. What is your understanding of the commitment involved in accepting a UCCF Program field internship?</p><p>2. What interests you about public child welfare or child protective services? Discuss any key event(s) that led to your interest in the UCCF stipend program and in becoming a social worker in public child welfare.</p><p>3. Describe the values and ethics that are important child welfare social work.</p><p>4. Describe some of your experiences in working with ethnically diverse populations.</p><p>5. What personal/financial issues or circumstances might be obstacles to successfully completing the demands of a field internship? How do you plan to deal with these?</p><p>6. What are some personal strengths and limitations that you might bring to public child welfare?</p><p>UCCF Application 2017-18 F.Y. Rev 2-16-17 4</p>