The University of Memphis Department of Social Work Social Work Information Form

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1 The University of Memphis Department of Social Work Social Work Information Form The Department of Social Work wants to know something about each of the students who is selecting Social Work to be her/his major. Please complete the information requested below (including the supplementary essays) and submit them to the Department. BACKGROUND INFORMATION Date: Name: UID Number: Primary Contact Phone Number: Cell #: University Address: Residential Address: Permanent Address: The information requested immediately below assists us in documenting the diversity of our student population for our accrediting body, the Council on Social Work Education: Gender: Male Female Birth date: Race / Ethnicity: African American / Black Native American Hispanic or Latino Asian American Caucasian / White Pacific Islander Multiracial / Other (please specify) ** The University of Memphis and the Department of Social Work do not discriminate on the basis of sex, ethnicity, age, religion, national origin, sexual orientation, or political preference. Page 1

2 EMPLOYMENT INFORMATION Do you have experience working in a social service agency or social service setting as an employee? Please list each of these below, including the approximate time frames in which you were involved in these activities: Do you have experience serving in a social service agency or a social service setting as a volunteer? Please list each of these below, including the approximate time frames in which you were involved in these activities: EDUCATIONAL INFORMATION Have you attended another university or college? Yes No If yes, please list the school(s): Have you ever been enrolled in a Social Work program at another university or 4-year college? Yes No If yes, please list the school(s): Please explain why you did not complete the program: Have you ever been placed on academic probation? Yes No If yes, what is your current academic status? Are you currently enrolled as a full-time or part-time student? Full-time Part-time Page 2

3 Have you ever received any academic honors? Yes No If yes, please describe the honors along with the school(s) or organization(s) that awarded you: Please indicate the grade you earned in each of the following courses, along with the dates of completion. If there is a course listed that you have not taken, please write N/A in the grade column: Course Prefix Course Number Grade Semester of Completion ENGL 1020 ANTH 1200 PHIL 1611 SOCI 3422 BIOL 1010/1011 BIOL 1020/1021 SOCI 1010 PSYC 1030 ECON 2020 POLS 1030 SWRK 2010 SWRK 2911 Are you currently enrolled in SWRK 2010? Yes No In SWRK 2911? Yes No Tentative Graduation Date: Page 3

4 ABILITY TO PRACTICE IN THE FIELD OF SOCIAL WORK Have you ever been convicted of a felony? Yes No If yes, please explain as this information is vital for licensing and placement purposes: Do you currently have any legal action(s) pending against you? Yes No If yes, please explain: In the past two years, have you had any general medical, mental health, or substance abuse conditions that could impair your ability to practice social work? Yes No If yes, please provide a detailed explanation on a separate sheet of paper. ** Please note that this information is requested for purposes related to licensure processes associated with working in the profession of Social Work, as well as field assignment considerations. FUTURE PLANS Do you have any significant responsibilities outside of school? Yes No If yes, please explain: If you are employed, do you plan to remain employed during the remainder of your undergraduate studies? Yes No If yes, please provide the approximate amount of hours you will work per week: Page 4

5 If you are employed while attending school, what arrangements will you make to ensure that you can complete a field placement which requires at least two (2) days per week over two (2) semesters? Do you plan to attend graduate school in the future? Yes No If yes, in which field? Social Work Other (Please Specify) What are your career interests in Social Work? ADDITIONAL INFORMATION Please attach two (2) essays to this application form: 1) PERSONAL GOALS STATEMENT The first essay should be approximately three (3) pages long, typed, double-spaced, and providing the following information: Your work and volunteer experience The important facets of your identity and the people and experiences that have made important contributions to your identity Your personal strengths that you believe will assist you in becoming an effective social worker The limitations that will challenge you as you seek to become an effective social worker The values that are important to you and how they complement the values of the social work profession Your short term (5-year) and your long term (more than 10 years) professional career goals Page 5

6 2) CRITICAL THINKING ESSAY Please attach a second essay to this application, which should be two to three (2-3) pages (typed, double-spaced), that demonstrates critical thinking analysis about the following: Compare and contrast client populations with whom you would enjoy working (e.g., the elderly, physical abuse, low-income, etc.) and the client populations that would pose problems for you. What are the key positives and negatives about each client group? How are they similar? How are they different? Which issues will you need to address about either group? How will you address them? **Please note that these essays will be assessed for both content and writing skills. CONFIRMATION By signing this page, I confirm that I have read and that I fully understand the Social Work Student Handbook. I confirm that all of the information I provided in the screening form is correct and true. I also confirm that I will abide by the Code of Ethics of the National Association of Social Workers (NASW). Please Print Name: Signature of Student Date Please return this inventory and the two essays to the Department of Social Work main office: The University of Memphis Department of Social Work 226 McCord Hall Memphis, TN **Please note that the screening form, essays, and references cannot be ed or faxed. If you have any questions about this process, please call (901) Page 6

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