Field Experience Application

Social Security Number:

Phone Number:

Email Address:

Permanent Address

Street:

Local Address

Street:

In Emergency notify:

Phone:

Major(s):

Minor(s):

Cumlative GPA:

Licensed driver?:

Car available during placement?:

Preferred term(s) for placement
Spring Summer Fall

Number of Credits: 10 semester credits; A minimum of 450 hours spread over the entire 14 week semester. Correction 497: Capstone Seminar is to be taken in the same semester for 2 credits. Participation in the seminars is included within the normal agency 40 hour week.

Describe your career objectives.

Describe the type of field placement you would like to have. (Type of agency, type of work, type of client, geographic location, other relevant characteristics, which are important to you.) Please indicate at least two choices.

Have you completed the Courses required for the major _____, and, if relevant to the proposed fieldwork, list other courses which you have completed by the time you enter the field. Include any certificates (such as chemical dependency) or licenses.

The following questions relate to situations, which an employing agency may consider to be risk factors. Your responses will not necessarily prevent you from entering fieldwork but may require discussion with the field agency prior to placement.

If your answer to any of the following questions is "yes," please explain thoroughly on a separate sheet and submit it to the Field Practice Coordinator or schedule a private interview with the Field Practice Coordinator.

1. Have you ever been adjudicated as a juvenile or convicted of a adult criminal offense (exclude minor traffic crimes)?
   
2. Have you ever been charged with or dismissed from a job, internship, volunteer, or other field related experience for sexual harassment or sexual abuse of clients or colleagues?
   
3. Have you ever been treated for chemical dependency?
   
4. Have you ever been treated for mental illness or emotional problems?
   
5. Have you ever been denied, dropped from or failed an internship or other field based learning experience?
   
6. Do you have any physical condition that will necessitate special consideration in selection of a field placement?
   

If so, please describe your situation including need for special access, restrictions on activity, possibility of acute episodes such as seizures, diabetic reactions, etc. If there is any other information about you or your background that is not called for elsewhere in this application but which might be relevant to your placement, please provide it also. Use separate pages and submit it to the Field Practice Coordinator.

Employment and Volunteer History

Begin with most recent experience. Include any special skills and interests that may be relevant to the proposed internship. If you have additional experiences you would like to submit please write them on a seperate piece of paper and submit them to the Field Practice Coordinator.

Organization:

From (month and year):

To (month and year):

Type of experience
Work Internship Volunteer
Other:

Special Skills and Interests

Total hours completed:

Supervisor's name:

Describe what you did:

A Learning Contract is required. The broad educational objective for all students in internships is to acquire knowledge, skills, and insights which will facilitate entrance into a professional role in the human services. Conduct a self-assessment and then personalize the broad objectives to make them specific to you following the instructions in the learning contract guidelines.

1. An unofficial copy of your current transcript must be provided to the Field Practice Coordinator to establish eligibility. An additional copy may be required by the agency.
2. One copy of a sample of your writing must be submitted to the Field Practice Coordinator. It should be brief (one to two pages) and be representative of your writing ability. Portfolio assignments are appropriate.

Authorization and Certification

I give my permission for a copy of this application and related materials including my transcript to be provided to prospective field supervisors. To the best of my knowledge, the information provided in this application and related materials is true and accurate. Following submission of this electronic application please contact the Field Practice Coordinator (Dr. Les Schultz) to schedule a meeting.

First and Last Name:

Date: