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2023-24 Social Work BSW Field Practicum Student Application

Department of Social Work
Tricia Snyder, Field Coordinator
email: tsnyder@brockport.edu

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  • This application requires an up-to-date field placement resume:
    1. Use the RESUME TEMPLATE.
    2. Save the resume as either a Microsoft Word (doc/docx) or Adobe (pdf) file ONLY (one - two pages maximum)

    Additional information can be found on our Field Education Website.

  • STUDENT INFORMATION

  • Name: Name: *
  • Must be 9 digits.   Currently Entered: 3 digits.

  • RELEASE OF INFORMATION AUTHORIZATION AND TRAINING AGREEMENT

  • As part of the field placement assignment process, the Social Work Field Coordinator will need to share student placement materials and other relevant information with potential agencies / field instructors. This includes discussions with the prospective field instructor, and sending a copy of the student's resume to the potential field agency.

    By signing this agreement:

    I hereby give my permission to SUNY Brockport to release any and all information included in my Application for Field Placement to potential agencies/field instructors for the purposes of arranging field placement(s). This release extends to several agencies when necessary for confirmation of a mutually agreeable placement site.

    In consideration for participating in the Undergraduate Program of SUNY Brockport, and for receiving field practicum training at Affiliate agencies and or organizations that have entered into Affiliation Agreements with the College,

    I hereby agree to the following:

    1. The student shall assume full responsibility for their travel while assigned to Affiliate.

    2. The student acknowledges understanding that SUNY Brockport and NYS have no liability for the student's transportation; the student further acknowledges that they assume responsibility through their own liability automotive insurance for any travel, including but not limited to transporting field practicum clients in the student's vehicle during field practicum.
          2.1 Students who are under the insurance of another party must have signatures from the insuring party that they understand that there is no liability assumed by the University for students who choose to drive clients.

    3. The student shall assume responsibility to ask the affiliate about the policies and procedures regarding client transportation during the field practicum interview process, prior to accepting the field practicum.

    4. The student acknowledges that Affiliate retains the ultimate authority to control decisions by students in relation to client services and interventions.

    5. The student agrees to observe the rules, regulations, policies and procedures, and dress codes of Affiliate.

    6. The student agrees to follow the NASW Code of Ethics.

    7. The student agrees to abide by HIPAA confidentiality guidelines.

    8. The student declares that they are free from any health impairment that is of potential risk to patients or to other staff, employees, or that may interfere with the performance of their duties, including habituation or addiction behavior altering substances.


    **Students completing field internship at a health care agency may be required by the agency to demonstrate proof that they are free of active Tuberculosis within one year prior to field placement at the affiliate agency. Some agencies also require proof of health care insurance.

  • By signing this form, the student agrees to be bound by the terms of this release of information and student agreement.

  • Draw or Type
    I understand this is a legal representation of my signature. Clear

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