SWK 3350: Agency Information Form

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Congratulations on securing a volunteer position for SWK 3350 Social Work Experience! Please complete all questions below to confirm your placement with the Field Office.

This form is due no later than Saturday, June 1, 2019 at 11:59 pm.

If you have any questions, please contact Karina Benabe, MSW at kpacker3@msudenver.edu.

Student Information

First Name *

Last Name *

900 Number *

Email Address *

Primary Phone Number *

Agency Information

Name *

Mailing Address *

Supervisor Name *

Supervisor Email Address *

Supervisor Phone Number *

Start Date of Volunteer Placement *

年

月

日

Anticipated Volunteering Schedule *

List specific dates and times

Is your agency experience paid? *

Yes

If paid, what is your hourly wage?

Describe all the volunteer activities you will be involved in at the agency. *

For example: assist in the set-up and clean-up for evening groups; talk to clients and help them sign-in as they arrive; observe and participate in weekly groups about bullying; staff the front desk and provide resources to walk-in clients; staff crisis line; etc.

I confirm that I have been offered and accepted a volunteer position at this agency. *

I understand I must complete all 60 hours of volunteer experience to receive course credit. *

I understand that any information about my progress in this volunteer experience or other coursework may be shared only with relevant persons, including appropriate faculty, staff, and agencies and only as necessary to fulfill the obligations of this volunteer experience and BSSW program requirements. *

I understand that failure to successfully complete the volunteer experience in one agency setting over the course of one semester may result in dismissal from the course and/or a performance review. *

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