North Carolina Child Welfare Education Collaborative

MSW Child Welfare Training Waiver INFORMATION DATA FORM

Complete this form only if you are planning to complete NC Division of Social Services Child Welfare Pre-Service Training requirements.

See the Collaborative Liaison or Coordinator for instructions and additional information

Date of application: __________________________________

MSW P

ROGRAM



Application for Academic Yr. Beginning 20 _______ Ending 20 _________

____

ECU

Full Time Program

Part-Time Program



____

JMSW

Have you previously applied to the Collaborative?

Yes

Location if part-time program



____

UNC-CH

If yes, application was for

MSW Program

BSW Program

ART

Name _____________________________________________________________________________________________________________

Title (Ms., Mr., Mrs., or Dr.)

Last

First

Middle

Preferred

Address ____________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

City

State

Zip

Telephone: Home (

)

Work(

) _________________ Email Address ________________________

Birth Date: ____________________________________ Gender: _________________ Ethnicity/Race ________________________________

Is English your primary language?  Yes

 No

If No, what is your primary language?

In addition to your primary language, what languages do you speak?

Language

Level of Proficiency (check one)



1. _____________________________

basic

intermediate

read only





2. _____________________________

basic

intermediate

read only





3. _____________________________

basic

intermediate

read only



What will be your MSW program status during the academic

In what MSW curriculum track will you be enrolled during the academic

period for which you applying? Check one:

period for which you are applying?



 Full Time  *Part-time *If Part-time, what year will you be in the

 Foundation  Advanced  Advanced Standing

program?

Expected Graduation Date ______________________

Check one: 1

2

 3

4

Have you ever been convicted of any unlawful offense (other than a minor traffic violation)?  Yes

 No

If Yes, list the date of the conviction and crime for which you were convicted: ______________________________________________________

____________________________________________________________________________________________________________________

ART

Are you currently employed by a county Department of Social Services or by NC Division of Social Services? Yes No

If No, go to Part Three of this form. If Yes, will you continue your current employment while a student? Yes No

If Yes, Name of Agency: ________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________

Agency Telephone (

) _________________ FAX: (

) ________________________________________________________________

Position Title ________________________________________________________________________________________________________

Supervisor's Name _________________________________________ Dates of Employment From

Are you (or will you be) on educational leave from this agency? Yes No

_________________________________________________________________________________________________________________________________

North Carolina Child Welfare Education Collaborative - Msw Waiver Data Form

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