California State University, Los Angeles



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DEPARTMENT OF SOCIAL WORK, MSW PROGRAM

Geriatric Social Work Education Consortium (GSWEC)

2019-20 Application Form

Completed Application due no later than: January 30, 2019

|ONLINE APPLICATION option (Click the link below and submit online instead): |

| |

| STUDENT INFORMATION: |

|Name:       |Student ID#       |

|Local Address:       |Date of birth:       |

|City:       |State & Zip:       |Gender: Male Female |

|Permanent Address:       |Phone number:       |

|City:       |State & Zip:       |Cell Phone:       |

|MSW Specialization: Clinical Community |MSW Program Cohort: 2 YR Full Time 4 YR Part Time |

| |Advanced Standing Full Time Advanced Standing Part Time |

|Please notify MSW Program of any address or email changes throughout |APU Email address:       |

|the academic year to avoid a delay in correspondence. | |

|Emergency contact & phone number:       |

|Citizenship Status:       |

|LANGUAGE SKILLS (other than English) |

|      |

|Language(s) spoken |Rate verbal & written fluency |Can you conduct interviews |Can you write |Are you knowledgeable about the |

| |on a scale of 1-5 |& assessments? |reports? |culture associated with this language? |

| |1=least fluent, 5=most fluent | | | |

|       | | Yes No | Yes No | Yes No |

| |Verbal:       Written:       | | | |

I. INTERNSHIP AGREEMENT

      I understand that this internship requires that I maintain in good standing in my MSW program.

(Initial)

      I understand I must have the use of an automobile, a valid driver license, automobile insurance and

(Initial) a clear DMV Record and Background Clearance.

      I understand that Wednesdays are a required field day in GSWEC.

(Initial)

      I understand that I must bring a copy of this application to each of my GSWEC interviews.

(Initial)

      I understand that I must attend the GSWEC Agency Orientation on February 13, 2019.

(Initial)

____________________________________________ ____________________________

Signature Date

II. PERSONAL STATEMENT FOR GSWEC APPLICATION 2019-20

Please answer the following question in essay format. Limit your response to 550 words and attach your response to this application form. There is no “right or wrong” answer, but it serves as a means of assessing your interest in geriatric social work:

Why do you want to complete an internship in a geriatric social work setting? Please include prior experience you have had with older adults and their families.

| |

|Please email or drop off completed application & personal statement to (or any questions): |

|APU Department of Social Work, MSW Program |

|Attn: Jean Un, APU GSWEC Liaison at jun@apu.edu |

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