Social Work Department

- - - Field Agency Application - - -

Students begin the placement process in February for the school year which begins the following August.

This application will let me know a little about your agency and whether we have something to offer each other in the education of social work students. It is intended to help us communicate, so if you have any questions or concerns, please phone me at 303 556-4663 or send me an EMAIL.

You may either complete this form on line and EMAIL it to me, Lynn Kaersvang, at Kaersval@mscd.edu or you may print it out and mail it to me: Lynn Kaersvang, Field Coordinator, Metropolitan State College of Denver, Social Work Department, Campus Box 70, P.O. Box 173362, Denver, CO 80217-3362. When I receive your application, I will phone or email you to set up a time when we can talk.

Application to be a Field Placement Agency

*REQUIRED: If submitting your application on-line, ALL required contact information must be completed for submission.

Identifying Information:

Agency Information

*

Agency Address

*	*	*	*
Street	City	State	Zip

Agency Phone Number(s):

(1)*
(2)
(3)
Person Completing This Form, Name:
*	Title or Position in agency
Phone: (if different from above)
Pager	Cell
Email	Fax
Web Site: Please check this box if you do NOT want to grant permission for MSCD's Social Work Department to share your web site with others. *REQUIRED: If submitting your application on-line, ALL required contact information must be completed for submission.

Agency/Field Placement Focus:

1. Please describe the populations served by your agency:

2. Please describe the services offered by your agency:

3. Please describe the opportunities that would be available for a student to work with individuals, families, groups, organizations and the community.

4. Are there sufficient learning opportunities available for students to keep busy with continued growth for 16 hours a week from August through the first week of May?

Supervision:

1. How many degreed social workers does your agency employ who would be interested in serving as field instructors/supervisors for a student:
BSW:	MSW:
2. If your agency does not employ a degreed social worker, is there a social worker serving as a board member, consultant or in another related role who knows your agency well and would be willing to serve as a field instructor/supervisor for a student?

Placements:
1. How many BSW students field placements can your agency provide?
2. Would it be possible for a student to complete his/her field placement during evening and weekend hours, with social work supervision available, at your agency? Yes No

Agreements:

I have accessed the Field Manual on line, or requested that it be mailed to me, and am aware of the information it contains.

I have read the Goals and Mission of the Social Work Department at Metropolitan State College of Denver, and consider that a Field Placement at this agency would support and enhance the mission of the Department as well as that of this agency.

I have read the Structure of the Field Placement (link) and understand the basics of the Field Placement.

I have read the Affiliation Agreement and will have it signed and mailed to the Social Work Department.