Springfield College: Mast Head Image
AGENCY ACCEPTANCE FORM:
For Springfield College – School of Social Work
Note: If more than one student is to be placed within the same agency,
a separate form must be completed and submitted for each student.
*Required Fileds
Student Information
Date: 02/10/2012
*Student First Name:*Student Last Name:
*Practicum: 1st 2nd*Program: Weekday Weekend Adv. Standing
Parent - Agency Information
*Legal Name:
Mailing Address:
*Address:*City:*State:*Zip:
*Main Phone:
( ) -
Ext. 		Fax:( ) -
Chielf Administrator:
*First Name:*Last Name: *Title:
Initial Contact:
Person with overall responsibilities for student internships
*First Name: *Last Name:
*Degree(s):
MSW
BA MED PHD DPE
BS MS EDD Other
If you selected Other, please describe:
*Title/Poistion: *Email:
*Phone:( ) -
Ext. 		Fax:( ) -
Direct Supervisor Responsibilities: If different from above, please enter follwing fields.
**Primary Supervisor must hold an MSW; In MA, Primary supervisor must also be licensed at LCSW Level.
1. Primary Field Supervisor:
First Name: Last Name:
Degree(s):
** MSW
BA MED PHD DPE
BS MS EDD Other
If you selected Other, please describe:
Licensed:
*** LCSW Level
Title/Position: Email:
Phone:( ) -
Ext. 		Fax:( ) -
1. Secondary Field Supervisor:
First Name: Last Name:
Degree(s):
MSW
BA MED PHD DPE
BS MS EDD Other
If you selected Other, please describe:
Title/Position: Email:
Phone:( ) -
Ext. 		Fax:( ) -
Location of Placement:
(Agency, Program, Department, Unit) where practicum will occur;
if different from above please enter following fields.
Location Name:
Location Address: Location City:
Location State: Location Zip:
Location Phone:( ) -
Ext. 		Location Fax:( ) -
The agency agrees that:
1. Students will be provided with learning opportunities consistent with the Advanced Generalist learning objectives (for more information please visit School of Social Work/Supervisor Resources/Download Forms and see: "Mission Statement", "Field Practicum Activities and Academic Products", and "Purpose of Field Education").
2. Field Supervisor(s) will meet with the student(s) a minimum of 1.5 hours per week in face-to-face supervision throughout the two semesters of practicum.
3. Field Supervisor(s) will make up supervision hours cancelled by the supervisor.
4. Field Supervisor(s) will arrange for back-up supervision if supervisor is absent for more than one week. Absence of more than three weeks requires negotiation with the Faculty Advisor and arrangements for a qualified MSW substitute Supervisor.
I agree to the above supervisory conditions in items 1-4 above. By checking this box, you acknowledge that you, acting as the Primary Field Supervisor, have read and understand the above four supervisory conditions, and accept these responsibilities.
*Primary Field Supervisor's Full Name

*Title:
*Date: / /
Please Attach:
  • A Primary Field Supervisor's latest resume:
    -We will accept MS Word (.doc)/plain text (.txt) resume file. Please click Browse button to attach a resume file.
  • An address of the informational web site/page describing your agency (if not provided within the last five years):
    • If you are a new agency and/or field supervisor, please attach both of the above.
    Thank you for joining us in creating valuable social work education experiences!
    School of Social Work Field Office
    263 Alden Street Springfield MA 01109