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Yeshiva University



• Please complete this two (2) page form in order to begin the placement process for first year of field. This form will be
used to plan your field placement experience and will be sent to your field placement agency.
• Please note that there may be processing requirements for certain internships, such as: background checks, medical
screening, fingerprinting, etc. The student is responsible to pay for any costs associated with these requirements.
• IMPORTANT: Agencies are requiring background checks for employees and interns. If there is anything in your
background that you would like us to consider in placing you, please contact the Field Instruction office to discuss.

Please submit this form with your resume.

Mr.______ Ms.______

Name____________________________________________________ DOB_____________________________________
(Last) (First)

Student ID #_____________________________________________ Home Phone________________________________

Present Address___________________________________________ Office Phone_______________________________

________________________________________________________ Cell Phone_________________________________

(City) (State/Zip)

School E-Mail____________________________________________________________________

Summer Address __________________________________________________________________________________

(City) (State/Zip)


Check off ONE:
PEP Program - Field Placement at Place of Employment _____
CONCURRENT Program -School-Assigned Field Placement _____
BLOCK Program Field Placement – School Assigned Field Placement _____
BLOCK Program Field Placement at Place of Employment _____

Are you enrolled in the Summer Block Program? (if yes, please indicate below in which program) Y_____ N_____

_____Summer Block I _____Summer Block II

Are you an international student? Y_____ N_____ Do you speak a language other than English? Y_____ N_____

If yes, please specify________________________________

Practice Method Specialization:
Clinical Practice with Individuals and Families______ Clinical Practice with Groups_____

Community Social Work_____

First year field placement is an opportunity to develop basic social work skills and learn about the profession. Please let us know
about any areas of special interest. We will take that into consideration, but cannot guarantee a specific type of placement. We
do guarantee an excellent learning opportunity.

Special Factors:
Please list any factors/circumstances that should be taken into consideration when planning your field placement (e.g.) Geography,
time, physical condition, religious observance, family commitments, etc.:

Are you dependent on public transportation? Yes No

Driver’s License: Yes No Availability of car: Yes No

Projected Practice Method Specialization: (This is only a projection)

Clinical Practice with Individuals and Families_____ Clinical Practice with Groups_____

Community Social Work_____

Please click here to submit form