Field Student Profile Form

Please complete all fields

Job/Title:	Employer/Agency:	Dates:	Full-time/Part-time/Volunteer:
Placement level (check one)	Field I	Field II
Pick Semester to Begin Placement	Summer	Fall
Indicate Year to Begin Placement	Year
Child Welfare Scholar (Check one)	Yes	No	Application Being Considered
Name:
Date:
Complete Local Address: (number,street,city,state,zip)
Phone Number:
E-Mail:
Undergraduate Degree:
Major:
University Attended:
Graduation Date:
Graduate Degree/Study
University Attended for Grad School
Degree Awarded or credits completed:
Date of Graduation or Study:
Related Education List/describe additional experiences which you think have contributed to your social work education(workshops, training,etc,)




Field Placement Experience: (describe duties)
Dates:
Field Placement Agency:
Do you have a valid driver's license?	yes		no
Do you have access to an automobile?	yes		no
Do you have auto insurance?	yes		no
Any physical limitations that impact field placement?	yes		no
If yes to physical limitations, describe: