PERTINENT

PAPERS FOR
FIELD
DEPLOYMENT
OF
SOCIAL WORK
INTERN

NAME : Regine O. Ramonal

COURSE & YEAR : BSSW IV
BLOCK : A1
SUBJECT : Field Instruction 1 & 2
SEMESTER : First & Second Semester
SCHOOL YEAR : 2024 – 2025
 Table of Contents
01 Registration Form
02 Student Internship Program Application Form
03 Student Internship Program Application Letter
04 Student Personal Data Sheet
05 Medical Examination Report/Medical Certificate
06 Parents/Guardian Affidavit of Consent
07 Parents/Guardian Waiver
08 Student Liability Waiver
09 Code of Ethical Standard of Social Work Intern
 Republic of the Philippines Department:
Yllana Bay View College, Inc. Document Code:
Pagadian City
STUDENT INTERNSHIP PROGRAM Rev. No:
REGISTRATION FORM Effective Date:

Date:_________________

Name:________________________________________________________
(Last) (First) (Middle)

Program Course & Major: __________________

Year & Block:_______________
School I.D Number: ________________
School Portal Username:___________________

______________________________________
SIGNATURE OVER PRINTED NAME

Reviewed by:

____________________________________ ___________________________________
FIELD SUPERVISOR FIELD COORDINATOR

_______________________________________
BSSW PROGRAM HEAD
 Republic of the Philippines Department:
Yllana Bay View College, Inc. Document Code:
Pagadian City
STUDENT INTERNSHIP PROGRAM Rev. No:
APPLICATION FORM Effective Date:

Semester: ______________________ School Year: _______________________

Name: ___________________________________ Program/Curriculum: __________________________

Year & Block: _____________________________ I.D Number: __________________________________
Date Attended the Orientation: ____________________________________

____________________________________ ___________________________________
FIELD SUPERVISOR FIELD COORNIDATOR

______________________________________
BSSW PROGRAM HEAD

*Please present this upon enrollment

 Republic of the Philippines Department:
Yllana Bay View College, Inc. Document Code:
Pagadian City
STUDENT INTERNSHIP PROGRAM Rev. No:
APPLICATION LETTER Effective Date:
Regine O. Ramonal, RSW
SUPERVISING INSTRUCTOR

Maam,
I, ___________________________ a 3rd year BS in Social Work student would like to apply for Bachelor of
Science in Social Work Internship for this academic year 2024-2025, I am very much willing to undergo the
training after the evaluation.
Hoping of your kind and consideration.

Very truly yours,

1. Evaluation NIEL D. TALPIS, MPA

REGISTRAR OFFICE IN-CHARGE
_____________
UNITS/GWA

2. Recommendation

BENAFE A. MAGHUYOP, RSW, MSW (CAR)

ASSISTANT OF THE OFFICE OF THE ACADEMIC AFFAIRS/BSSW PROGRAM HEAD
Recieved: _______________ Date Received:_____________

REGINE O. RAMONAL, RSW

SUPERVISING INSTRUCTOR
CS FORM 212 (Revised 2005)

P ERSONAL DAT A SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME | | | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME | | | | | | | | | | | | | | | | | | | | EXTENSION

3. NAME | | (e.g.
| Jr.,| Sr.) | | | | | | |
16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy) ../..../..
5. PLACE OF BIRTH

6. SEX
Male Fem ale
7. CIVIL STATUS
Single Widowed ZIP CODE
Married Separated
17. TELEPHONE NO.

Annulled Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP

9. HEIGHT (m)

10. WEIGHT (kg) ZIP CODE

11. BLOOD TYPE 19. TELEPHONE NO.

12. GSIS ID NO. 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any)

14. PHILHEALTH NO.

22. AGENCY EMPLOYEE NO.
15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME 12.../...15..../..2004

MIDDLE NAME 12.../...15..../..2004
OCCUPATION 12.../...15..../..2004
EMPLOYER/BUS. NAME 12.../...15..../..2004
BUSINESS ADDRESS 12.../...15..../..2004
TELEPHONE NO. 12.../...15..../..2004
(Continue on separate sheet if necessary) 12.../...15..../..2004
26. FATHER'S SURNAME 12.../...15..../..2004
FIRST NAME 12.../...15..../..2004
MIDDLE NAME 12.../...15..../..2004
27. MOTHER'S MAIDEN NAME 12.../...15..../..2004
SURNAME 12.../...15..../..2004
FIRST NAME 12.../...15..../..2004
MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST GRADE/ INCLUSIVE DATES OF
28. YEAR SCHOLARSHIP/
NAME OF SCHOOL DEGREE COURSE LEVEL/ ATTENDANCE
LEVEL GRADUATED ACADEMIC HONORS
(Write in full) (Write in full) UNITS EARNED
(if graduated) From To RECEIVED
(if not graduated)

ELEMENTARY

SECONDARY

VOCATIONAL /
TRADE COURSE
COLLEGE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES SALARY GRADE
GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY M ONTHLY & STEP STATUS OF
SERVICE
(Write in full) (Write in full) SALARY INCREMENT APPOINTM ENT
(Yes / No)
(Format "00-0")
From To

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(mm/dd/yyyy) POSITION / NATURE OF WORK
(Write in full) HOURS
From To

02../.13./.1997 02../.13./.1997

02../.13./.1997 02../.13./.1997

02../.13./.1997 02../.13./.1997

02../.13./.1997 02../.13./.1997

02../.13./.1997 02../.13./.1997
(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
in full) HOURS (Write in full)
From To

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
33. SPECIAL SKILLS / HOBBIES: 34. 35. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
36. Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged?
YES NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL YES NO
or phased out, in the public or private sector? If YES, give details:
________________________________
________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)?
If YES, give details:
________________________________
________________________________
41. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:

a. Are you a member of any indigenous group? YES NO

If YES, please specify: ____________________
b. Are you differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)

43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and Computer generated
or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential. PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4

 Yllana Bay View College
The Builder of Future Leaders



P A R E N T/G U A R D I A N AFFIDAVIT OF CONSENT

I, ___________________________________________, of legal age, filipino, married and a resident of

________________________________________________________________________ after being sworn to in
accordance with the law, do hereby depose and say:

That I am the guardian of ________________________________________, a fourth year Bachelor

of Science in Social Work student of Yllana Bay View College, Inc., Balangasan District, Pagadian
City;

That my son/daughter is going to undergo the Internship Training Program of the Yllana
Bay View College; Social Work Department.

That the said Internship Training Program is an academic requirement for graduation to
the degree of Bachelor of Science in Social Work.

That I understand the importance and necessity of the said program as an Academic
requirement for Graduation to the degree of Bachelor of Science in Social Work

That I am giving my consent to my son/daughter to undergo the Internship Training

Program;

That I am expecting this affidavit to attest the veracity of the aforementioned facts for the
purpose of putting into writing my approval to him/her joining the said program.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______day of

___________________ 2024 at __________________________________________________.

WITH MY CONSENT AND APPROVAL:

___________________________________
Signature over printed name of Parent/Guardian/Spouse
 Yllana Bay View College
The Builder of Future Leaders



P A R E N T/G U A R D I A N WAIVER

TO WHOM IT MAY CONCERN:

Let it be known to all that, the undersigned, MR. /MRS. / MS.
_____________________________________, parent/guardian of__________________________________, a 4th
year BS Social Work student who is going to undergo the Internship Training Program as an
academic requirement for graduation with the degree of Bachelor of Science in Social Work.

Let it be known further, that I am waiving my right to question whatever damage, harm,
injury, or wrong he/she may sustain to himself/herself or may incur to others if the same ensued
or came about in excess or abuse of the authority granted to him/her or for the improper conduct
in the performance of his/her duties and responsibilities as intern, even if committed within the
time covered in the Internship Training Program and whether inside or outside the
office/establishment is assigned.

Let it be known finally, that I am not holding Yllana Bay View College, Inc. Administration
responsible for whatever damage, harm, injury or wrong my son/daughter/ward/wife/husband will
incur to himself and to others in the manner of aforementioned in the preceding paragraph as
he/she accomplish the Internship Training Program as an Academic requirement necessary to
complete his/her degree for Bachelor of Science in Social Work.

Witness my hand and seal this ______ day of _____________________ 2024 at Pagadian City,
Philippines.

____________________________________________

(Parent/ Guardian)

Witnesses:

BENAFE A. MAGHUYOP, RSW, MSW (CAR) REGINE O. RAMONAL, RSW

Assistant Academic Officer Field Supervising Instructor
Yllana Bay View College, Inc. Department of Social Work
 Yllana Bay View College
The Builder of Future Leaders



STUDENT LIABILITY WAIVER

I, _________________________________________, a Bachelor of Science in SOCIAL WORK of

Yllana Bay View College, Inc., with residence at
________________________________________________________________________, hereby voluntarily agree
to join in the INTERNSHIP/ON – THE – JOB – TRAINING (OJT), from _____________ (____ days
exclusive of Saturdays and Sundays) at _________________________________________.

I therefore understand that the said internship/on – the – job training is one of the major
requirements for my degree and that I fully understand that the purpose of the said
INTERNSHIP/OJT is for me to be exposed in a real life situations related to my course, educate
and orient myself to the latest and social reality of our society base on the following terms and
conditions;

1. That I shall take charge of all the expenses incurred for the execution and entire
duration of the INTERNSHIP/OJT.
2. That I shall abide by the Rules and Regulations of the Company I am deployed in and
the Coordinator of the INTERNSHIP/OJT Program, otherwise, I shall be excluded from
further participation.
3. That I shall further exercise care, honesty and diligence in any task assigned to me.
4. That I shall renounce and waive my claim against the officials of the
School/Company/Establishment for any injury I suffer, particularly in the performance
of my duties and functions while under INTERNSHIP/OJT.

Signed this ______ day of _____________________ 2024, ________________, Philippines.

____________________________________________________
Signature over printed name of Student-Trainee
 YLLANA BAY VIEW COLLEGE, INC.
COLLEGE OF SOCIAL WORK
Enerio Street, Balangasan District, Pagadian City
“The Builder of Future Leader”

CODE OF ETHICAL STANDARD OF SOCIAL WORK INTERN

As an Intern at Yllana Bay View College, I, ___________________________________ obliged to

follow the rules and regulations implemented by the College of Social Work and ready to
uphold the obligations stated below:

1. I will not report to my internship assignment under the influence of drugs or

alcohol.
2. I will not engage nor participate in using or be influence myself to use any types of
illegal drugs.
3. I will not make promises or commitments that I cannot keep.
4. I will not tolerate verbal exchange of a sexual nature with my co-worker or engage
in behavior that might be perceived as sexual with my co-worker or with my client.
5. I will not tolerate verbal exchange in behavior that might be perceived as
discrimination against an individual on the basis of their age, race, gender, sexual
orientation, ability or ethnicity.
6. I will not engage in any type of business with my clients during the term of my
internship.
7. I will not enter into personal relationship with my co-worker or to my client during
the term of service.
8. I shall not engage in pregnancy during my internship.
9. I will not commit any actions to sabotage the College of Social Work and the
institution.
10. I shall not wear any of my uniforms used in my internship during off duty.
11. I shall not use any vulgar words.
12. I will not participate or engage in any disorder, riot or serious violation of the
law in my area of assignment.
13. I shall not participate in, condone, or be associated with dishonesty, fraud, or
deception.
14. I shall not receive any monetary amount from my client as exchange to my
service.
15. I shall not forget to wear a smile as always.
16. I will report to my assignment area on time and avoid being late and
constant absences.
17. I shall follow an order coming from my instructor and staff from this
institution.
18. I shall maintain my proper hygiene and pleasing personality.
19. I will observe the proper dress code.
20. I will participate in any form of activities in the community provided for the
good and betterment of the community.
21. I will uphold the seven principles of social work.
22. I will be held accountable for everything I publish on social media.
23. I am committed to behaving in a manner that is consistent with the following
principles and ethical values to achieve the best value, respect, honor, and
institution and maintain public confidence in the authority.
As an intern, I will abide and conform to the Code of Ethical Standard set by the College of Social Work of
Yllana Bay View College. My internship ( Field 1 and 2) will be suspend if found out to have violated the Code
of Ethical Standard set by the College of Social Work.

Signed this ___ day of ______________ 2024, in Yllana Bay View College, Enerio Street,
Balangasan, Pagadian City, Philippines.

WITH MY CONSENT AND APPROVAL:

 ___________________________________
Signature over printed name of Parent/Guardian/Spouse

_________________________
Name and Signature (Intern)