X

Venus George
Student
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: George, Venus L

2.Student ID #: 1094066

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

4.Date of application: 09/17/2017

5.Expected date of graduation: 05/2018

6. Age: 53

7.Local address during school year: 1105Fort Clarke Blvd, # 1601, Gainesville, Florida 32606
8.Local phone number: (352) 204-5544

9.Person to notify in case of emergency: John George, 1105 Fort Clarke Blvd, # 1601,
Gainesville, Florida 32606

10.Ethnic/Racial Background:
White (non-Hispanic) ____
African American/Other Black_X_
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]: WV University of Technology, SanteFe

Community College

14.Practicum experience while attending previous college(s): [if applicable] N/A

15.Interests and hobbies: Helping Others

16.Types of volunteer experiences and/or civic or social groups affiliated with: [other than
required practica] 12 Step Program Volunteer

17.Do you have transportation for field placement? [Explain in detail.] Yes. I have my POV

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? No
[If yes, please explain in detail. detail.]

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: 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. No.

2.Special Qualifications: [check those applicable]

Driver's License X Computer Literacy X Foreign Language

3.Do you have any physical, psychological, or emotional health issues which may
interfere with you fulfilling the requirements of the field internship? No

4.It is the students responsibility to provide transportation for the field

internship. Explain how you plan to fulfill this responsibility. The use of my personally
owned vehicle.

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. Substance Abuse

2. Homelessness

3. Child Abuse

7. If you are working during the semester of your field placement, what
arrangements have you made to complete the required field placement
hours? Arrangements will be made with current employer to work 10 hour shifts to
allow time for internship for 1 day of the week and 1 day on the weekend. (Friday and
Saturday)

8. Have you ever been arrested and/or convicted of any criminal offense? If yes,
please explain.
Yes__X_ No__(2005 an arrest which charges were dropped )

9. Please check ALL that apply to you:

a. Preferred Number of Hours Per Week to Complete Internship

_____ Complete 32 hours per week (full-time) Completion in one
semester

__X___ Complete 16 hours per week (part-time) Completion of

remaining hours over the second semester.

b. Preferred Time of Day to Complete Hours

_____ Monday Friday Day Recommended hours are 8:00am
4:00pm

_____ Monday Friday Evening Recommended hours are 3:00pm

11:00pm

___X__ Saturday Friday Day Recommended hours are 8:00am

4:00pm

c. Preferred Distance from Internship to Place of Residence

_____ Less than 10 miles_____ 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

_____ Individual Clients (Micro)_____ Groups (Macro)

__X___ Community Work/Advocacy (Macro)

 PART FOUR: ACKNOWLEDGEMENT AND SIGNATURE PAGE

Please understand this application does not mean you have been admitted into the
social work major and/or for a field placement. During this semester, your application
will be reviewed by the Social Work Professional Standards Committee and you will
subsequently participate in an interview with a member of that committee. You will
receive official notification re: your admission status once grades are posted at the end
of the semester.

The Social Work Department reserves the right not to admit a student to the social
work major; not to place a student in the field; or to remove a student from field
placement if the student demonstrates academic failure, exhibits unprofessional
conduct or inappropriate behavior in the classroom or related in the field
placement.

In rare cases, agencies have requested that a student be removed from field
placement due to the student's unacceptable behavior. In such a case, students will
not be offered another field placement.

Falsification or withholding of information on this application may result in denial to

the social work major, denial of a field placement, removal from field placement or
removal from the major. If changes take place after the this application is first
submitted, the Department Chair and/or Director of Field must be immediately
notified in writing what those changes are, particularly if the student has
subsequently been arrested or convicted of a crime.

This page (Part Four) must be signed (electronically) and submitted with Part One, Part
Two and Part Three of this application to the social work major.

I, _Venus George____________________________________________________ have read in

its entirety the
(full name)

Social Work Student Handbook, 2017-2018 and am aware of my rights and responsibilities
which govern my acceptance into this program.
Signed:_______________________________________________

Date:__09/17/2017_____________________________________________

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.