Bethel University Social Work Program

Agency Information Form

Agency Name:

Address/City/State/Zip:

Agency Website:

Agency Phone/Fax:

Coordinator/Contact Person:

Coordinator/Contact Phone#:

E-mail:*

Field Instructor Name(s), Degree(s), License(s):

Description of Agency:

What are the possible learning activities available to students:

Are there specific hours the student needs to work on a weekly basis?

Yes

Please Specify

Is there a specific orientation plan held by the agency?

Yes

If so when?

Interested in a junior field placement 160 hours.

Yes

How many junior students can you place at your agency?

Interested in a senior field placement for 400+ hours.

Yes

How many senior students can you place in your agency?

Can the agency offer the student evening and weekend hours?

Yes

Does the agency prefer a student in a block placement?

(30 hours a week beginning January - May)

Yes

Does the student need to use a personal car for transporting clients?

Yes

Is the agency wheelchair accessible?

Yes

Does the agency conduct criminal background checks on students?

Yes

Does the placement present any out-of-the-ordinary personal safety risks for students?

Yes

Is there any other information you want us to know?

I agree that the submission of this form indicates our interest in becoming a field site for the Bethel Social Work Program.*

Date Submitted:*