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: Ash, Chandler B.

2. Student ID #: 1104790

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

4. Date of application: 10/5/2017

5. Expected date of graduation: May 2019

1. Age: 21

7. Local address during school year: 21015 SW 119th Ave Archer, Florida 32618

8. Local phone number: 352-538-5607

9. Person to notify in case of emergency: [name, address, phone number]

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 ____
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]: Santa Fe College

14. Practicum experience while attending previous college(s):

15. Interests and hobbies: Music, Video production and editing

16. Types of volunteer experiences and/or civic or social groups affiliated with:

17. Do you have transportation for field placement? Yes, I have a truck.

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__X__

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 ____NO __X__

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) $____________________________

Part Two is on the next page

 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

 PART THREE: FIELD APPLICATION

1. Do you have any personal obligations which may prevent you from completing your field
internship? If yes, please explain.

2. Special Qualifications: [check those applicable]

Driver's License X Computer Literacy X Foreign Language

2. Do you have any physical, psychological, or emotional health issues which may interfere
with you fulfilling the requirements of the field internship?

I have asthma and a grass allergy, which would only interfere if the internship was
primarily outdoors for an extended period of time.

3. It is the students responsibility to provide transportation for the field internship. Explain
how you plan to fulfill this responsibility.

I own a reliable pickup truck.

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. Children

2. Families

3. Teens/Young adults

4. If you are working during the semester of your field placement, what arrangements have
you made to complete the required field placement hours?
 My job is extremely flexible with work hours, and I have the ability to make my own
schedule to work around academics.

5. Have you ever been arrested and/or convicted of any criminal offense? If yes, please
explain.
Yes_____ No_X___

6. 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

__X__ Less than 10 miles _X___ 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)

__X__ Community Work/Advocacy (Macro)