This is not an interactive application. Please print out an application and fax or mail it to:  The University of Tennessee at Martin, Department of Behavioral Sciences, Sociology Building, Martin, TN  38238  -- fax (731) 881-7514).

 

                                   APPLICATION FOR STUDENTS

                                               INTERESTED IN

                              SCHOOL SOCIAL WORK LICENSURE

 

Date of Application  __________________________    Advisor  _______________________________

 

Name  _______________________________________________   SS#  _______________________

 

Local Address  ______________________________________  Phone #  _______________________

 

Permanent Address  __________________________________  Phone #  _______________________

 

 

Email Address  __________________________________  Cell phone #  _______________________

 

Racial/Ethnic Background*  _________________________________              Gender*  ____F  ____M

*Information to be used only for reporting purposes to accrediting bodies

 

I am:

__________  (a)  currently a social work student at The University of Tennessee at Martin

                             If so, are you:

                             _______  a pre-major

                             _______  approved for initial progression

                             _______  approved for advanced progression

                             _______  approved for full progression

 

__________  (b)  a transfer student

 

                             from:  ___________________________________________________________

 

                             major:   __________________________________________________________

 

__________  (c)  a graduate

 

                             from:  ___________________________________________________________

 

                             degree:  BSSW _______           MSSW  _______             Other  ______________

 

 

 

 

Are you enrolled in or have you completed any of the following courses:

 

                                       Course                                          Grade                              University

 

____  Social Work in a School Setting (SWRK 375)           _____           ________________________

 

____  Educational Psychology (HLRN 325) or                    _____           ________________________

          (TCED 716)                                                             

____  Exceptional Child (SPED 300/500)                            _____           ________________________

 

____  The School, the  Teacher, and the Law                       _____           ________________________

           (EDST 450/650)

 

____  Social Work Field Instruction in a                               _____           ________________________

          School Setting (SWRK 490)                 

 

Please list any post-graduate work experience in a school or family and children's service setting.

 

___________________________________________________________________________________________

             School                                            Address                                    Date                         Supervisor

 

___________________________________________________________________________________________

             School                                            Address                                    Date                         Supervisor

 

___________________________________________________________________________________________

             School                                            Address                                    Date                         Supervisor

 

(Please provide documentation of successful employment with this application.)

 

Admission to the School Social Work Curriculum is:

 

____ Approved    ____ Denied                     _________________________________________________________

                                                                     Social Work Program Representative

 

____ Approved    ____ Denied                     _________________________________________________________

                                                                     Social Work Education Representative

 

 

FIELD INSTRUCTION

School Placement:

_____________________________________________________________________________________________

               School                                            Address                                     City/State                             Zip Code

 

_____________________________________________________________________________________________

            Contact Person                                                          Phone

 

____  Approved     ____  Denied             ____________________________________________________________

                                                                 Social Work Program, Field Coordinator

 

____  Approved    ____  Denied              ____________________________________________________________

                                                                School of Education, Director of Student Services

 

 

RECOMMENDATION FOR SCHOOL SOCIAL WORK LICENSURE

 

__________________________________________________  has successfully completed all requirements for the School Social Work Licensure as approved by The University of Tennessee at Martin Department of Education and Social Work Program, and is therefore recommended for School Social Work Licensure.

 

____  Agree    ____  Degree                    ____________________________________________________

                                                                Department of Education Coordinator for Admissions and Licensure

 

____  Agree    ____  Degree                    ____________________________________________________

                                                                Social Work Program, Program Director