Asbury College

Social Work Program Application

Baccalaureate Social Work Program

 

Prof Steve Dawson, Chair

Prof Steve Dawson, Social Work Program Director

Prof James R. Johnson, Field Placement Director

Admission Application:

Name _______________________________________________ SS #_______________

(Last) (First) (Middle or maiden)

School Address _________________________________ School phone #___________

Home Address __________________________________ Home phone #____________

Reference letters are required of three persons familiar with you and your potential as a social worker. These persons may be former employers, pastor, youth pastor, parent, etc

Please fill in the names and addresses of the references on the lines below and the program director will send the requests to your references.

Please check one of the following two options.

____ I waive my right to review any and all references pertaining to my application to the Asbury College Social Work Program.

____ I do not waive my right to review any and all references pertaining to my application to the Asbury College Social Work Program.

Reference one ________________________________________________________________________

 

Reference two

________________________________________________________________________

Reference three ________________________________________________________________________

 

________________________________________________________________________

Please supply the name of one faculty member who is not a member of the Sociology/

Social Work Department and is qualified to evaluate your potential as a social worker.

 

Please supply a one-page vita of your employment and volunteer experiences, starting with the most recent experience.

Asbury College non-discrimination policy:

Asbury College does not discriminate on the basis of race, color, gender, age, ethnic origin, or handicap in the admission of students, educational policies or programs, employment policies, and activities. In addition, Asbury College does not discriminate on the basis of religion in the admission of students and student access to educational programs.

 

 

Social Work Program Application

 

In a one-page essay, please write (typed or word processed) your reasons for wanting a career in social work. Identify the influences, life experiences, and strengths you possess that can be used to help people. Discuss ways in which your Christian faith can be integrated with your social work profession. Please place your signature and date at the end of the essay.

 

Authorization to Release/Exchange Confidential Information

I, , - -

(Student’s name – printed) (Student ID #)

Authorize the Asbury College

Student Counseling Service / Office of Student Development

One Macklem Drive

Wilmore, KY 40390

(Approve by initialing only one of the following)

______ TO RELEASE TO:

Office of:

Social Work Program Director

Dept. of Sociology and Social Work

Asbury College Post Office

the following information about services I received from the Student Counseling Service (initial all that apply):

X Date(s) and type of service(s) received only

X Results of assessments, and recommendations

X Progress

X Other: (Specify) Please forward to this office, a summary report on the above named student’s moral ethical

and behavioral fitness for admission to the Social Work major.

The purpose(s) of releasing this information is (are): (Please see attached form.)

I understand that no disclosure of my records can be made without my written consent, unless otherwise provided by law, and that I may revoke this authorization in writing at any time, except to the extent that information has already been released. I want this authorization to expire (initial one only):

______ Sixty (60) days from the date below authorizing this release, or the end of the semester, whichever occurs last.

______ Six (6) months from the date below or six (6) months after termination of services, whichever occurs last.

X On the day the record is destroyed, which is at the end of the 5^th academic year after my last contact with the SCS.

 

 

__________________________________________ (Client’s signature) (Staff Member)

 

 

__________________________________________

(Date) (Witness)