Request For Student Interns

Requesting Students:

Agency Field Survey of Learning Opportunities

Please fill out the form and press "SEND" at the bottom of the page.

* indicates required fields
* Name of Agency/Program:
Agency/Program Address:
Agency/Program Zip:
Agency Website Address:
*Agency Contact Person:
Agency Phone:
* E-mail Address:
YES * Does your agency have multiple locations
NO that would host student interns?

In order to direct students with particular interests, Please check the field(s) of practice that BEST describe your agency. (Check all that apply)

Aging / Gerontology Social Work Staff Training/Personnel Development
Mental Health Data Analysis
Health Medical Community Organization
Substance Abuse Human resource Management
Schools Program Development/ Evaluation
Children, Adolescents and Families Policy Development
Disabilities Research
Corrections/ Criminal Justice Grant Writing
Homeless Legislative Lobbying
IPV/DV Community Outreach
Immigration/Refugees Advocacy
Grief and loss
LGBTQ* Other

Please describe the practice experiences planned for your students:.

Please select your preferred field concentration and the number of students desired for each concentration:

How many total students can your agency accept?

Undergraduate
Yes No #: (September - May)
(1st Field) Generalist
Yes No #: (September - May)
(2nd Field) Clinical
Yes No #: (September-May)
Yes No #: Block (Summer only - 5 days/week, May - August)
Yes No #: Summer/Fall (May- December)
(2nd Field) MACRO
Yes No #: (September - May)
Yes No #: Block (Summer only - 5 days/week, May-August)
Yes No #: Summer/Fall (May - December)
Advanced Standing Clinical
Yes No #: May - May
Advanced Standing Macro
Yes No #:

May - May

Check all additional requirements needed for placement:

Travel/car required (non-transport of clients)
Car not required, but highly desirable
Driver’s License Required
Medical Clearance Required
Handicapped Accessible Elevator
Ramp
Bathrooms
Is Paid placement available
(attach additional information)
Yes
No
Criminal Background Check/Fingerprinting
Child Abuse Registry Check Required

Other Requirements (please explain)

Field Instructor's Name # 1

Site Location

Address

Highest Degree BSW
MSW

Completed SIFI

(Seminar in Field Instruction)

Yes No

Phone Number

Email Address

Field Instructor's Name # 2

Site Location

Address

Highest Degree
BSW
MSW

Completed SIFI

(Seminar in Field Instruction)

Yes No

Phone Number

Email Address

Field Instructor's Name # 3

Site Location

Address

Highest Degree
BSW
MSW

Completed SIFI

(Seminar in Field Instruction)

Yes No

Phone Number

Email Address

Additional information we need to know:



Thank you.