FOUR PART APPLICATION TO THE SOCIAL WORK MAJOR:

Complete and submit all four (4) sections of the application to the social work major in this
online survey. This includes:
Part One: Demographic Information (#1 through #20)
Part Two: Personal Statement (#1 through #9)
Part Three: Field Application (#1 through #9)
Part Four: Acknowledgment and signature page (electronic signature is accepted)

The deadline to submit this application is Monday, September 25, 2017. Late submission, or if
any part of the application is missing, will result in conditional admission to the social work
major.

PART ONE: DEMOGRAPHIC INFORMATION

1. Name: [last, first, middle] SMITH, TONI, R

2. Student ID #: 001092388

3. Location (ex: Gainesville, Tampa, etc.): GAINESVILLE, FLORIDA

4. Date of application: OCTOBER 4, 2017

5. Expected date of graduation: 2019

6. Age: 43

7. Local address during school year: 5757 SW 49 ST

GAINESVILLE, FL 32608
8. Local phone number: 352-317-5407

9. Person to notify in case of emergency: [name, address, phone number] DYLAN SMITH
3900 YORKETOWNE BLVD UNIT 4801
PORT ORANGE, FLORIDA 32129

10. Ethnic/Racial Background:

White (non-Hispanic) ___X_
African American/Other Black ____
Chicano/Mexican American ____
Puerto Rican ____
Other Latino/Hispanic ____
American Indian/Native American ____
Asian American/Other Asian ____
Pacific Islander ____
Other ____
Multiple Race/Ethnicity ____
Unknown ____

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11. Are you a foreign student (no resident visa)? YES ____ NO __X__

12. Do you require any accommodations under section 504 of the rehabilitation act or the
Americans with Disabilities Act? YES____ NO__X__ [if yes, please explain.]

13. Previous college(s) attended [if applicable]: SANTE FE COLLEGE

GAINESVILLE, FL

14. Practicum experience while attending previous college(s): [if applicable] I AM CURRENTLY
WORKING AT NORTH FLORIDA REGIONAL AS A UNIT CLERK. I WORK WITH SOCIAL
WORKERS DAILY. I HAVE TO READ SOCIAL WORKERS NOTES TO CHECK ON PENDING
DISCHARGES AND HAVE TO CORRESPOND WITH SOCIAL WORKERS TO HELP WITH
STATUS OF PLACEMENT FOR PATIENTS PRIOR TO BEING DICHARGED.

15. Interests and hobbies: LOVE SPENDING TIME WITH MY KIDS AND READING.

16. Types of volunteer experiences and/or civic or social groups affiliated with: [other than
required practica] N/A

17. Do you have transportation for field placement? [Explain in detail.] YES, I HAVE MY OWN
TRANSPORTATION TO MY FIELD PLACEMENT.

18. Are there are personal circumstances of which you are aware that could possibly affect your
ability to complete the requirements of the social work program? Yes No
[If yes, please explain in detail.]

Loan Debt
Please provide information about loan debt. CSWE and the National Association of Social Workers
(NASW) use this critical data in advocacy and public work.

19. Will you or have you acquired loan debt while working towards your BSW?
YES X____NO ____

20. If you answered YES to the above question, what do you anticipate will be the average
amount of your loan debt (acquired while working towards your BSW) when you graduate?
(Please indicate the amount) $__40,000.00__________________________

Part Two is on the next page

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 PART TWO: PERSONAL STATEMENT

This is to be a double spaced, typed personal statement essay. This essay should describe any
relevant personal experience or background that brought you to the decision to enter the social work
profession. Please include in your personal statement the following eight items:

1. Reasons for choosing to attend Saint Leo University

2. Reasons for choosing to major in social work

3. Perceived qualities and strengths that will benefit you as a social worker

4. Professionally, your expectations of what you hope to be doing five years after graduation

5. Educational experiences (if applicable)

6. Any relevant life experiences

7. Any relevant family history and relationships

8. Any other relevant information

Part Three is on the next page

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 PART THREE: FIELD APPLICATION

1. Do you have any personal obligations which may prevent you from completing your field
internship? If yes, please explain. NO

2. Special Qualifications: [check those applicable]

Driver's License X Computer Literacy X Foreign Language

3. Do you have any physical, psychological, or emotional health issues which may interfere with
you fulfilling the requirements of the field internship? NO

4. It is the students responsibility to provide transportation for the field internship. Explain how
you plan to fulfill this responsibility. I HAVE RELIABLE TRANSPORTATION.

5. Do you understand that there are no funds available from the University for any expenses
related the field internship and that you will be expected to finance all travel, housing, and food
expenses involved in your internship? Yes _X__ No ______

6. Type of population/social issue preferred. List three (3) in order of preference. This does not
guarantee that you will be able to be placed in your first choice. This serves as a guide for field
staff. Students do not find their own field placements.

1.DOMESTIC VIOLENCE

2.SUBSTANCE ABUSE

3.CHILDREN AND FAMILY

1. If you are working during the semester of your field placement, what arrangements have you
made to complete the required field placement hours? I HAVE PLANNED TO WORK
AROUND MY FIELD PLACEMENT HOURS. MY JOB ALLOWS ME TO MAKE SET DAYS
THAT I WORK.

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2. Have you ever been arrested and/or convicted of any criminal offense? If yes, please explain.
Yes__X___ No_____
I PURCHASED A GIFT CARD FROM A FRIEND AND WAS UNAWARE THAT IT
WAS STOLEN. I WAS CHARGED WITH A MISDEMEANOR FOR USING STOLEN
PROPERTY OF LESS THAN $100.

3. Please check ALL that apply to you:

a. Preferred Number of Hours Per Week to Complete Internship

___X__ Complete 32 hours per week (full-time) Completion in one semester

_____ Complete 16 hours per week (part-time) Completion of remaining hours

over the second semester.

b. Preferred Time of Day to Complete Hours

__X___ Monday Friday Day Recommended hours are 8:00am 4:00pm

_____ Monday Friday Evening Recommended hours are 3:00pm 11:00pm

_____ Saturday Sunday Day Recommended hours are 8:00am 4:00pm

c. Preferred Distance from Internship to Place of Residence

_____ Less than 10 miles _____ 20 30 miles

___X__ 10 miles 20 miles _____ More than 30 miles

d. Preferred Geographical Area of Internship:

_____ Rural _____ Urban __X___ Either

e. Preferred Focus of Population

___X__ Individual Clients (Micro) _____ Groups (Macro)

_____ Community Work/Advocacy (Macro)

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Part Four is on the next page

PART FOUR: ACKNOWLEDGEMENT AND SIGNATURE PAGE

Please understand this application does not mean you have been admitted into the social work major
and/or for a field placement. During this semester, your application will be reviewed by the Social
Work Professional Standards Committee and you will subsequently participate in an interview with a
member of that committee. You will receive official notification re: your admission status once
grades are posted at the end of the semester.

The Social Work Department reserves the right not to admit a student to the social work major;
not to place a student in the field; or to remove a student from field placement if the student
demonstrates academic failure, exhibits unprofessional conduct or inappropriate behavior in the
classroom or related in the field placement.

In rare cases, agencies have requested that a student be removed from field placement due to the
student's unacceptable behavior. In such a case, students will not be offered another field
placement.

Falsification or withholding of information on this application may result in denial to the social
work major, denial of a field placement, removal from field placement or removal from the
major. If changes take place after the this application is first submitted, the Department Chair
and/or Director of Field must be immediately notified in writing what those changes are,
particularly if the student has subsequently been arrested or convicted of a crime.

This page (Part Four) must be signed (electronically) and submitted with Part One, Part Two
and Part Three of this application to the social work major.

I, _______________TONI R SMITH______________________________________ have read in its

entirety the
(full name)

Social Work Student Handbook, 2017-2018 and am aware of my rights and responsibilities which
govern my acceptance into this program.
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Signed: __TONI R SMITH_____________________________________________

Date: __October 3, 2017_____________________________________________

The deadline to submit this application is Monday, September 25, 2017. Late submission, or if
any part of the application is missing, will result in conditional admission to the social work
major.