Name: MSW Stipend Child Welfare Education Program Application Form

CHILD WELFARE EDUCATION PROGRAMMSW STIPEND APPLICATION

Last Name:________________________ First Name:_________________________

ASU ID:________________________ Social Security#:_______________________

ASU e-mail address (if applicable):____________________________

Secondary e-mail address:_____________________________________

Primary Ph#:________________________ Secondary Ph#:_________________________

Physical Street Address:__________________________________________

City, State, Zip:_____________________________________________

Mailing Address (if different from physical address):________________________________

City, State, Zip:_____________________________________________

How did you hear about this program (Check ALL that apply)?

____ in a Community College class, identify the class: ____________________________

____ in a class at ASU, identify the class: ___________________________________

____ at a Career Fair or conference, identify the location of the event: ___________________

____ from a friend or colleague

____ through the School of Social Work’s Website

____ from an electronic announcement in the lobby of the School of Social Work

____ from an email announcement to students in the School of Social Work

____ through my advisor at a Community College or ASU

____ through a tour or event associated with an ASU visit or field trip

____ from a flyer or brochure

____ through the ASU scholarship database

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Name: MSW Stipend Child Welfare Education Program Application Form

For the following questions, please check the appropriate response.

I am applying for the MSW Stipend Program and will be attending the:

� Phoenix Downton Campus

� Tucson Campus

I am applying for admission into the:

� Advanced Standing MSW Program beginning in Summer ___________ (year)

� Standard MSW Program beginning in Fall ____________ (year)

My MSW application is (please check one): In order to receive ‘first round’ consideration, applicants need to apply to the child welfare MSW Stipend program by the stated deadline and need to be accepted to the MSW program at ASU by that deadline. Other applicants may be considered in a ‘second round’ on a space available basis.

� Complete: All my required materials and fees for the MSW application have been submitted to the School of Social Work and the Graduate College.

� Incomplete: I have not yet submitted all of the required materials and fees for MSW admission.

In this Child Welfare MSW Stipend application, I have included the following:

� Completed Application Form (pgs. 1 - 6)

� DCS Release of Information Form, Intern Application, Certification of Criminal Offense, ASU Release of Information Form (pg. 7-14)

� Two page essay

Return all application materials to the Child Welfare Education Program

Mail to: Child Welfare Education Program Hand delivery: Room 880L School of Social Work University Center Arizona State University 411 N Central Ave Mail Code: 3920 411 N Central Ave Ste. 800 Phoenix, AZ 85004-0689

For further information, email Lindsey.Galvin@ASU.edu or call Lindsey at 602-496-0081.

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Name: MSW Stipend Child Welfare Education Program Application Form

Stipend Packages

Please rank-order your preferences of the stipend packages by placing a 1 next to your first choice and a 2 next to your second choice. Advanced standing students may only receive package C. Your preferences will be used as a guide in the selection process, however, there is no guarantee you will receive your preferred package. Please see the information about the Stipend Packages for more details.

____ Package A (Academic Year Stipend) – I understand I will be required to work full-time for AZ DCS for a minimum of 24 months upon graduation.

____ Package B1 (First Year Summer Block Stipend) – I understand I will be required to work full-time for AZ DCS for a minimum of 24 months upon graduation.

____ Package B2 (Second Year Summer Block) – I understand I will be required to work full-time for AZ DCS for a minimum of 24 months upon graduation.

____ Package C (Advanced Standing Stipend) – I understand I will be required to work full-time for AZ DCS for a minimum of 18 months upon graduation.

Child Welfare Curriculum

Students who receive a Stipend Package must follow the Public Child Welfare Specialization Curriculum. Please see the information about the CWEP curriculum for more details.

Note: All stipend students are required to complete on of their field practicums in one of our Child Welfare Education Units. These units focus on Direct Practice skills. They are not considered PAC placements and are not appropriate for PAC students as their second year field placement. Advanced standing Stipend students, therefore, may not be in the PAC concentration unless they were in our Education units as their BSW field placement or they have recent AZ DCS Case Manager Experience.

Please indicate below which concentration/specialization you will be pursuing by checking the appropriate response.

Advanced Standing Program:

____ I will be in the Direct Practice Concentration

____ I would like to pursue the PAC Concentration. I completed mu BSW field placement in one of the Child Welfare Education Units or I have recent AZ DCS case manager experience.

Standard Program:

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Name: MSW Stipend Child Welfare Education Program Application Form

____ I will be in the Direct Practice Concentration and understand that I will not be permitted to change to the PAC concentration if I did not complete my first year field placement in one of the Child Welfare Education Units.

____ I am considering the PAC Concentration and understand that although I will be in the PAC Concentration, I will be required to take Advanced Direct Practice courses as my PAC electives. I also understand that I will complete my first year field placement in one of the Child Welfare Education Units.

DCS Fit

The purpose of the Title IV-E Child Welfare Education Program is to recruit and educate skilled and competent social workers who desire to pursue a career in child welfare. The work of public child welfare is both rewarding and challenging. We encourage all potential students to gain as much insight as the cay about the work of DCS and their personal fit to that work in order to: 1)meet the purpose of the Stipend program, that of providing DCS with competent workers who are prepared to provide services to highly vulnerable children and families; and 2) ensure that the investment in your education does not pose an undue burden on you if you are ultimately unable to work at DCS and are required to pay back the scholarship money received. Please indicate which of the following resources you have reviewed in your exploration of the field of child welfare and your fit in a DCS position.

____ the Child Welfare Education Program (CWEP) website including the FAQs and Myths of CPS work

____ the AZ DCS Realistic Job Preview at: INSERT LINK HERE

____ the DCS website

____ the DCS Fit Checklist

____ had a face to face meeting with _________________________________ who is an employee of the ASU Child Welfare Education Program. We met on ____________________ (date).

Visited a Child Welfare Education Program Unit: Phoenix___ Tempe____ Tucson___ Apache Junction___ West 101___ Osborn___ Pinnacle Peak___

____Other efforts to determine fit with DCS (please explain):________________

__________________________________________________________________

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Name: MSW Stipend Child Welfare Education Program Application Form

DCS Work Requirements Stipend Eligibility and Essential Job Functions

To be eligible for consideration for any of the stipend packages students must be admitted as a full-time MSW student at ASU and be able to work at DCS in AZ for the time required following graduation. Additionally, students must be able to meet the DCS job requirements, including*:

being a U.S. citizens or having a work visa that would allow the applicant to meetthe work commitment

having a valid Arizona (or another state in the US) driver's license, insurance, anda vehicle capable of safely transporting at least 2 or more people in addition toyourself

the ability to visually assess the condition of the child and his/her homeenvironment for signs of abuse or neglect

compliance with the DCS driving policy

the ability to conduct home visits (including those homes that are not wheelchairaccessible);

the ability to use a computer and learn computer programs

the ability to interview children and adults proficiently in English

passing a CPS registry check (individuals who have had a substantiated report ofchild abuse or neglect against them will generally NOT pass this check)

passing a fingerprint background check/obtaining a Level One AZ FingerprintCard (individuals who have been convicted of a crime against a child, a felony, orof a DUI in the last 5 years will generally NOT pass this check)

passing an employment/reference check

While not being able to fulfill all of these essential functions does not automatically rule out any applicant, it is important for the stipend selection committee to know whether or not reasonable accommodations can be made. Please identify any accommodations on the application form.

Can you preform the essential functions of the DCS position (listed above) with no special accommodations?

____ Yes

____ No (please answer next question)

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Name: MSW Stipend Child Welfare Education Program Application Form

Please list any reasonable accommodations you would need to be able to perform the essential functions of the DCS position (you may use additional paper to explain).

_________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Are you currently a United States Citizen?

____ Yes ____ No (specify status below)

Status: ____________________________________________________________

Background Check

DCS has a mandatory fingerprinting and DCS registry background check requirement for all employees, volunteers, and interns. You must be able to receive a Level One Department of Public Safety (DPS) fingerprint clearance card in order to complete your field placement in a Child Welfare Education Unit and to be able to work for DCS. If you have had a DUI in the past 5 years, have ever been convicted of a crime against a child, or of a felony, you may not pass the criminal background check and will not be able to receive a fingerprint clearance card. If you have had a substantiated allegation of child abuse/neglect against you, you may not pass the DCS registry background check.

In some circumstances, you may be able to get a good cause exception if you initially do not receive a fingerprint clearance card or are initially screened out through the DCS registry. However, if you are unable to immediately obtain a Level One Clearance Card or pass the DCS Registry Check, you cannot be placed in/remain in a Child Welfare Education Unit. If you believe there may be some concerns or complications with you passing the mandatory DCS background checks, please speak with a CWEP staff person prior to signing the contract. If you sign the contract and received tuition assistance and or stipend money but are subsequently unable to pass the background checks, you will be required to pay back the full amount of assistance you received. Please check your response below.

____I believe I will pass the DCS background checks.

____ I have some concerns about passing the background checks and would like to speak to a staff member prior to being placed in a CWEU and /or signing the Stipend contract.

____I currently have an Arizona Level One fingerprint card.

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DCS-1254A (4-17) ARIZONA DEPARTMENT OF CHILD SAFETY

INTERN APPLICATION

NAME EMAIL ADDRESS CELL PHONE

ADDRESS CITY STATE ZIP

MAILING ADDRESS (If different)

REASON FOR INTERNING

CURRENT/PREVIOUS EMPLOYMENT CURRENT/PREVIOUS EMPLOYER CURRENT/PREVIOUS OCCUPATION

EMPLOYER’S ADDRESS (No., Street, City, State, ZIP)

SUPERVISOR’S NAME LENGTH OF EMPLOYMENT PHONE NUMBER

AVAILABILITY INDICATE THE DAYS AND HOURS YOU ARE WILLLING TO WORK NUMBER OF HOURS AVAILABLE PER WEEK/MONTH

INTERN EXPERIENCE (Where, When, Type of Work)

EDUCATION (Highest Level)

High School, College,

University, Trade School or

Business School

City and State Dates Attended Diploma/Degree and

Date Received Major Area of Study

REFERENCES (Persons Not Related To You)

1. NAME PHONE NUMBER

ADDRESS

2. NAME PHONE NUMBER

ADDRESS

STATEMENT OF CERTIFICATION

Have you ever been convicted of any crime, even if set aside or expunged?

Please note that a criminal conviction does not automatically disqualify you from interning.

YES NO

If YES, please provide the following:

DATE

/ / JURISDICTION CHARGE

Felony OR Misdemeanor

Do you currently have a valid Level One Fingerprint Clearance Card?

YES NO If YES, attach a copy of fingerprint card. If NO, use Fieldprint to obtain fingerprint card, if required.

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DCS-1254A (4-17) – PAGE 2

Have you had an entry of substantiated acts of child abuse or neglect in any other state’s or jurisdiction’s registry?

YES NO If YES, please explain:

All interns must consent to a search of the DCS Central Registry for any entries of child abuse. Please provide the following

information:

Date of Birth: Social Security Number:

INSURANCE

LIABILITY COVERAGE: Interns are persons doing State of Arizona work/activities under the direction and control of a State

authorized official and are not being paid. Liability coverage is extended to interns acting at the direction of a State official and within

the course and scope of their State authorized activities. Interns of the State are provided the same liability protection afforded

employees. Thus, interns acting within the course and scope of their State authorized activities may be covered for their liability exposure

as authorized interns of the State.

WORKERS’ COMPENSATION IS NOT COVERED: Interns are NOT covered by the State’s workers’ compensation plan if injured

while participating in this program. (Except for interns covered pursuant to A.R.S. 23-901.) Interns are strongly encouraged to obtain

their own medical insurance before participating in this program.

I certify that the above responses are true to the best of my knowledge. I agree to allow the Department of Child Safety to check my

references. I have carefully read the above information and understand its contents.

PROSPECTIVE INTERN’S SIGNATURE DATE

FOR DCS INTERNAL USE ONLY SUPERVISOR OF INTERN TITLE PHONE NUMBER

DIVISON/PROGRAM DUTIES OF INTERN BEGIN DATE

/ / END DATE

/ /

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA),

Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the

Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,

genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For

example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print

materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making

reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know

of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office;

TTY/TDD Services: 7-1-1. • Free language assistance for Department services is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios

del DCS está disponible a solicitud del cliente.

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Consent for Release of Educational Records and Child Welfare Program Application Materials

Name:

Address:

Relationship:

Arizona Department of Child Safety

3003 North Central Avenue, Phoenix, Arizona, 85012

Collaborative Partner with the ASU School of Social Work Child Welfare Education Program

By presenting a signed and dated copy of this consent to the Child Welfare Education Program, I consent to the release by ASU of any and all of my educational records and records submitted as part of my application to the Child Welfare Education Program and ASU School of Social Work to the individual(s) or agency named above. I further authorize that ASU may discuss the information contained in my educational and/or my application records with the authorized recipient(s). This consent applies to education records and/or application records that may otherwise be protected under the federal Family Educational Rights and Privacy Act of 1974, as amended, 20 U.S.C. 1232g, also known as the FERPA or the Buckley Amendment, a synopsis of which is available through the Registrar’s Office. This consent does not authorize the recipient to make decisions or process transactions on my behalf. This authorization will remain in effect until I rescind it in writing.

_______________________________________________________________Applicant Signature

Individual or Agency to Whom Access to Records May be Provided:

Note: The individual or agency authorized for access to records must provide appropriate identification at the time of access.

Applicant Name:

Affiliate ID Number: Date:

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