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Field Application for HPU Social Work (Fall 2021)

1.Your name
2.Your HPU Email
3.Your HPU ID #
4.What year will you be in the program in Fall 2021?
5.Which part of the Social Work program are you in?
6.Where on Oahu do you live? (Town/Neighborhood)
7.How will you get to practicum?
8.Will you be working during placement? 
9.Are you currently employed? 
10.If yes, who is your employer?
Please enter below the times that you ARE available for practicum. (For example 9a - 5p)
11.Monday
12.Tuesday
13.Wednesday
14.Thursday
15.Friday
16.Saturday
17.Sunday
18.Is this your 1st or 2nd Practicum?
19.Please describe any volunteer experience that you have. (Organization, what your responsibilities were, approximate dates.)
20.Please upload your resume here. (Required.)
No file chosen
21.Is there a specific agency that you are interested in working with? If so, please list: the name of the agency, a contact person and their telephone number.
22.Please check the top 3 areas of social work that you are interested in.
Please note: this is not a guarantee that you will get your first choice for practicum.
23.Please select what part of the island you would prefer to do your practicum.
24.Have you gotten the COVID-19 Vaccine or are you planning on it? (There are some sites that may require vaccination.)
25.Please provide any additional information that would be helpful in making your field placement assignment.
Please answer the following questions openly and honestly. Your response is essential in the practicum office locating your practicum placement, making decisions for future practicum placements and for discussing your strengths and weaknesses in this profession.
26.Have you ever been party to a civil lawsuit?
27.If yes, please explain in detail.
28.Have you ever been arrested or convicted of a misdemeanor or felony?
29.If yes, please explain in detail.
30.Are there any charges pending against you?
31.Have you ever had an allegation of either child or adult maltreatment (abuse, neglect, abandonment, exploitation, and/or childpornography) made against you that was substantiated or is pending against you?
32.If yes, please explain in detail.
If you answered “Yes” to any of the above questions, you will need to meet with the Director of Field Education to clarify any questions. Additionally, you may be asked to provide documentation on the nature of the offense/allegation and its disposition and a statement containing proof of rehabilitation, if applicable.
33.Please read the following and check below  that you have read and understand the statements below:
- I attest that all information provided in this application is true and accurate.
- I am aware that a criminal background check will be performed, and given the results may impact my practicum placement and/or professional social work degree.
- I understand that my application will be reviewed and discussed by HPU faculty to determine my readiness for practicum.
- I understand that I may be required to show proof that I am TB negative, and/or complete a physical and provide other medical information as necessary.
- I agree to follow the NASW Code of Ethics and HPU Practicum Manual.
-  I agree to comply with all the requirements of the practicum and at my site.
- I understand that my resume will be released to potential field instructors, and I hereby agree to release all information contained therein.
- I understand that any violation of the above stated requirements may result in my disapproval, suspension, or removal from the  practicum experience.(Required.)
34.Please enter your name and the date to "sign" this form.
35.Please list the name, relationship and contact information of your emergency contact.(Required.)
Thank you for taking the time to fill this out. The next step is to schedule a time to meet with the Director of Field Education. You can sign up for an appointment time here: https://calendly.com/jessicagarlock/30min. Meetings will be done via zoom.