ࡱ> )+&'(#` !bjbj >6I2>>>>A@6B VMVMVMVM=OWW\LՂׂׂׂׂׂׂ$Άh6MKfN@=OKfKfVMVMHhhhKf(VMVM#hKfՂhh[{~@}VM*B nS1>sf{~^0{‰f ‰(}‰}^(`hUb<c^^^h^^^KfKfKfKf-3d 3 MSW APPLICATION FORM Application Filing Fee - $60 (Non-refundable) PLEASE WORD-PROCESS OR PRINT Date  FORMTEXT       APPLICATION  PART I Note: To open an admission file in your name you must complete and submit Part I (A, B, C and D) of this application form and submit the application fee. Once Part I is received you will receive on-going communication about admission, financial aid, deadlines, etc. In addition, someone from the Admission Office will contact you as soon as Part I is received and will let you know what other materials, if any, have been received to date and what still remains outstanding in your admission application. Part II of this application includes your autobiographical sketch, the four letters of reference, your transcripts and Field Placement Form. For those applying Early Admission, the Preliminary Financial Aid Form is also included in Part II. These materials may all arrive separately either before or after sending Part I; materials will be set aside until Part I is received. For those applying BSW Advanced Standing and Transfer Students, Part II also includes the Case Summary Face Sheet Form, Case Summary, and the Social Work Employment Experience Form. Materials can be sent by mail (Smith College SSW, Lilly Hall, Office of Graduate Enrollment, Northampton, MA, 01063), by email to  HYPERLINK "mailto:sswapp@email.smith.edu" sswapp@email.smith.edu, or faxed to (413) 585-7990. Confirmation of emailed or faxed materials will be sent within 48 business hours; if you do not receive confirmation, please re-send. (Transfer Students are encouraged to call the Director of Admission at (413)-585-7962 to discuss their personal circumstances and appropriate supporting materials.) Part I Section A. Personal Information I am applying:  FORMCHECKBOX  Early Admission  FORMCHECKBOX  Regular Decision (Note: Early Admission applicants must submit all materials [see check list] by January 5; in turn you will receive a decision packet by the first week in February which will include your decision, the geography of your field placement and financial aid award if applicable. This offer must be accepted or declined within two weeks of receipt of the admission offer and cannot be deferred to the Regular Decision pool. If you have questions, please call the Office of Admission.) I am submitting this application for consideration for admission to the Smith College School for Social Work and desire to be enrolled in the following program:  FORMCHECKBOX  MSW  FORMCHECKBOX  BSW Advanced Standing  FORMCHECKBOX  MSW Transfer Student Legal Name in full  FORMTEXT        FORMTEXT        FORMTEXT       *Gender  FORMTEXT       First Middle Last Former last name(s) if any  FORMTEXT       *Date of Birth:  FORMTEXT        FORMTEXT        FORMTEXT       Date Month Year Preferred Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street and Number City State Zip Code Permanent Address (if different from the above:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street and Number City State Zip Code Home Telephone ( FORMTEXT    )  FORMTEXT    - FORMTEXT       Work Telephone ( FORMTEXT    )  FORMTEXT    - FORMTEXT       Cell Phone ( FORMTEXT    )  FORMTEXT    - FORMTEXT       Current E-Mail Address  FORMTEXT       (Important: email will be our primary mode of communicating with you about the status of your application; please be sure to include an email address which you will be checking regularly. If you have an auto-filter or spam blocker on your email, please be sure to authorize any email address ending in smith.edu and email.smith.edu so that our message can by-pass your filters.) Are you now or have you served with any branch of the United States military?  FORMCHECKBOX  No  FORMCHECKBOX Yes (Those responding yes may be considered for the SCSSW Scholarship for Military Personnel. Please contact the School for more information or visit our website at www.smith.edu/ssw) Are you a citizen of the U.S.?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If not a U.S. citizen, are you a permanent resident?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If you are a Permanent Resident, what is your Alien Registration Number?  FORMTEXT       If you are neither a U.S. citizen nor a Permanent Resident, of what country are you a citizen?  FORMTEXT       Country of Birth:  FORMTEXT       *Social Security Number  FORMTEXT     -  FORMTEXT     -  FORMTEXT      (Social security numbers are not required but are helpful in ensuring accurate matching of documents.) *Smith College seeks students of all racial and ethnic groups. If you wish to identify yourself as a member of a racial or ethnic group, please indicate below. If applicable, you may check more than one box. We invite you to be specific.  FORMCHECKBOX  Asian/Asian American  FORMTEXT        FORMCHECKBOX  Hispanic  FORMTEXT        FORMCHECKBOX  Native American/American Indian/Alaskan Native  FORMTEXT        FORMCHECKBOX  Black/African American  FORMCHECKBOX  Latino/a Tribal affiliation  FORMTEXT       (not Hispanic)  FORMTEXT        FORMCHECKBOX  Chicano/a Mexican-American  FORMCHECKBOX  Other  FORMTEXT        FORMCHECKBOX  Caucasian/White (not Hispanic)  FORMCHECKBOX  Puerto Rican  FORMCHECKBOX   FORMTEXT       *Dependent Child(ren), age(s)/gender(s)  FORMTEXT       (*Optional information, not required for consideration of application.) Are you fluent in any language other than English?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, what language(s)  FORMTEXT       Part I  Section B. Academic and Professional Training A transcript is required from all institutions from which you have received, or will receive a transcript. If you transferred credit from one school to the college from which you received your degree, the final transcript should not only include the courses, credits and grades from the degree granting courses, but also the courses, credit amounts and grades from the transfer college. If the course titles, credits and grades are not included on the final degree granting college transcript, you must also request a transcript from the college from which transfer credits were obtained. (Please note: this application does not require the GRE or the MAT. If you have taken these tests and would like to submit them with your application you are welcome to do so but you are not obligated and the vast majority of applicants do not submit these scores.) Do you have or are you in the process of completing your Bachelors Degree in Social Work (BSW)?  FORMCHECKBOX  yes  FORMCHECKBOX  no PLEASE PRINT (or attach word-processed page) Undergraduate college or universities attended:NUMBER OF YEARS ATTENDED FROM MO. YR. TO MO. YR. SUBJECTS Major Minor DEGREES AND DATES FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Graduate or professional: FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Distinctions, honors, awards, or other noteworthy accomplishments.  FORMTEXT       If you have applied for admission to any other school, please indicate the names of the institutions and status of your applications.  FORMTEXT       Do you plan to apply for financial aid from Smith?  FORMCHECKBOX  yes  FORMCHECKBOX  no How did you hear about Smith?  FORMTEXT       Part I  Section C. Work/Volunteer Experience Please attach a detailed resume that outlines your paid and volunteer experiences; include both human service related endeavors and non-human service related work; two (2) copies are required. Your resume should include the following categories if they apply: Your full name/address/phone/email Education: College(s) attended; degree(s) received and year in which the degree(s) was received Academic Awards date award was received and brief description of award criteria Paid Work Experiences: Dates worked (from to); approximate number of hours/weeks worked; your title, primary duties/responsibilities; name and title of your supervisor Volunteer Experiences: Dates worked (from to); approximate number of hours/weeks worked; your title, primary duties/responsibilities; name and title of your supervisor Other Awards or Other Relevant Information (Please note, if you are accepted and elect to attend Smith, this resume will be shared with the field agency to which you are assigned.) Part I Section D. References Please list below the names of those from whom we may expect to receive references. Indicate the capacity in which each reference has known you. Four professional and/or academic references are required of each applicant. Reference Name Relationship: # Years he/she has known you: 1.  FORMTEXT        FORMTEXT        FORMTEXT       2.  FORMTEXT        FORMTEXT        FORMTEXT       3.  FORMTEXT        FORMTEXT        FORMTEXT       4.  FORMTEXT        FORMTEXT        FORMTEXT       (Please note Because agencies often times ask for a background check, applicants are encouraged to consult with the social work registry board of your state regarding any restrictions to practicing social work should you have a criminal record.) I certify that the admission materials I provide are the result of my own work and represent information which is complete and accurate. I understand that the material submitted in connection with this application will be used for admissions selection and/or by faculty for academic and field work planning. Signed:  FORMTEXT       (If this form is being submitted electronically please forward a signed copy of this page to the school) The $60 application filing fee:  FORMCHECKBOX  is enclosed  FORMCHECKBOX  will be sent by mail with a signed copy of this page Need More Information? Please do not hesitate to call or write the Office of Admission. Or, if you prefer, we can connect you with an alumna/us or current student.  FORMCHECKBOX  I would like the name of a current student in my area to contact.  FORMCHECKBOX  I would like the name of an alumna/us in my area to contact. Admission material for those who are accepted and enroll in the School is subject to the regulations of the 1974 Family Education Rights and Privacy Act. APPLICATION PART II Part II: Part II includes the submission of your Autobiographical Sketch, your 4 letters of reference, official transcripts and your Field Placement Form. (If you are applying Early Admission, your Preliminary Financial Aid Form is also included in Part II.) For those applying BSW Advanced Standing or as Transfer students, also submit the Case Summary Face Sheet Form, Case Summary, and the Social Work Employment Experience Form. These materials may all arrive separately either before or after sending Part I. Materials can be sent by mail (Smith College SSW, Lilly Hall, Office of Graduate Enrollment, Northampton, MA, 01063), by email to  HYPERLINK "mailto:sswapp@email.smith.edu" sswapp@email.smith.edu, or faxed to (413) 585-7990. Confirmation of emailed or faxed materials will be sent within 48 business hours; if you do not receive confirmation, please re-send. Autobiographical Sketch An autobiographical sketch is required of all applicants. This sketch should describe those relationships and experiences (personal, political, social, familial, professional, therapeutic and educational) which you feel have developed your interest in, and readiness and suitability for the professional practice of social work. If you have experienced any major challenges in your lifetime, please comment on them and describe strategies you used to resolve or address them. What contributions do you hope to make as a professional clinical social worker? 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hP=5>*CJOJQJ^JaJ$hs_hv0JCJOJQJ^JaJ/jehs_hvCJOJQJU^JaJ)jhs_hvCJOJQJU^JaJ hs_hvCJOJQJ^JaJhvCJOJQJ^JaJh!CJOJQJ^JaJhvCJOJQJ^JaJh& 5CJOJQJ^JaJh& CJOJQJ^JaJQQQQRRRS/STSlSqSSSSS ! / 0 4 B W X Y Z ` b c d u     - . ʹʹʹʹʹʨʦʔʂtʹʨbʨʨt#hP=h6CJOJQJ^JaJhvCJOJQJ^JaJ#hP=h5CJOJQJ^JaJ#hP=h[V5CJOJQJ^JaJU hP=h]CJOJQJ^JaJ hP=h[VCJOJQJ^JaJ hP=hCJOJQJ^JaJ#hP=h5CJOJQJ^JaJ#hP=hv#*5CJOJQJ^JaJ$obiographical sketches should be word-processed and double-spaced; on average they run 6-8 pages.) Statement of Use If an applicant enters the program, the autobiographical statement becomes part of the students confidential file which is available to faculty for educational planning purposes only. Admission material for those who are accepted to and enroll in the School is subject to the regulations of the 1974 Family Education Rights and Privacy Act. MISSION STATEMENT: The mission of the Smith College School for Social Work is to advance the aims of the profession through education for excellence in clinical social work practice and through the development of knowledge. STATEMENT OF ANTI-RACISM: Smith College School for Social Work has committed itself to becoming an anti-racism institution. The School pledges to overcome racism in all of its programs. All programs are expected to monitor and report on their anti-racist efforts to the Anti-Racism Consultation Committee. NOTICE OF NONDISCRIMINATION: Smith College is committed to maintaining a diverse community in an atmosphere of mutual respect and appreciation of differences. Smith College does not discriminate in its education and employment policies on the bases of race, color, creed, religion, national/ethnic origin, sex, sexual orientation, age, or with regard to the bases outlined in the Veterans Readjustment Act and the Americans with Disabilities Act. The Smith College School for Social Works admission policies and practices are guided by the same principle, concerning applicants to its graduate program. The following office has been designated to handle inquires regarding the nondiscrimination policies: Director of Institutional Diversity, College Hall #31, (413) 585-2141.  To the Applicant: This form, for MSW, BSW Advanced Standing and Transfer Applicants, should be given to an individual who is able to comment on your qualifications for graduate study. Four reference letters are required; please copy this form as needed and give to Reference Writer. I waive the right to review my letter of recommendation:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of Reference Writer:  FORMTEXT       Applicant s Name:  FORMTEXT       Date:  FORMTEXT       To the Reference Writer: The above-named person has applied for admission to the Smith College School for Social Work MSW Program and has named you as a reference; please return this form with your letter. We are interested in obtaining information that will help us to arrive at a sound educational decision regarding this applicant and to plan a program if this applicant becomes a student. Unlike many schools, our academic calendar and clinical assignments require that, in a period of two and a quarter years, students may move up to five times and accommodate themselves to three different educational and treatment settings. Since social work makes heavy demands on its personnel, an individual who is selected must fulfill the academic requirements of graduate school and possess personal qualifications essential to the professional practice of social work. These qualifications include sensitivity to others, a particular aptitude for understanding and helping individuals, and qualities which will make a capable and responsible agency employee. In addition, adaptability, good judgment, creativity, and integrity are important. We would appreciate your general comments about the applicant. We would also welcome specific examples of the applicants experiences as they reflect a desire and ability to enter the profession of social work. The School complies with Section 504 of the Rehabilitation Act f 1973 and with the American Disability Act of 1991 banning the discrimination on the basis of disability. Under this regulation, the School may not make pre-admission inquiry as to whether an applicant for admission is disabled. Individuals who write letters of reference should not refer directly or indirectly to an applicants disability. Information regarding disabilities, voluntarily given or inadvertently received, will not affect any admission decision. In compliance with the Family Educational Rights and Privacy Act of 1974, it is the policy of the School that students who are admitted have access to their files which will contain your reference material. Since applications cannot be reviewed without reference material, a reply within two weeks of receipt of this letter will ensure prompt consideration of this applicants credentials. Please send reference material to: Smith College School for Social Work, Office of Admission, Lilly Hall, Northampton, MA 01063. Letters of reference may be received by fax at (413) 585-7990 or email at  HYPERLINK "mailto:sswapp@email.smith.edu" sswapp@email.smith.edu; please note Reference for [name] in the re: line of the email message. Please note that all emailed or faxed references which are not on letterhead and include a signature must be followed by hard copy via regular mail. Please return this form with your letter of recommendation. Sincerely, Irene Rodriguez Martin, Director Graduate Enrollment REFERENCE LETTER FORM 4 Letters required Qc d u . /        gd3gd2BgdwUgd[Vgd . / ] `        ۻzczzN=/hvCJOJQJ^JaJ hwUh2BCJOJQJ^JaJ)hwUhxB*CJOJQJ^JaJph,hwUhAyCJOJPJQJ^JaJnHtH hwUh1CJOJQJ^JaJhwUCJOJQJ^JaJ hwUhwUCJOJQJ^JaJ hP=h1CJOJQJ^JaJ hP=hCJOJQJ^JaJhv6CJOJQJ^JaJ#hP=h[V6CJOJQJ^JaJ#hP=h]6CJOJQJ^JaJ K,.0xgxgYgKg: hP=h[VCJOJQJ^JaJhvCJOJQJ^JaJhP2CJOJQJ^JaJ hP=h3CJOJQJ^JaJ&hP=h35CJOJQJ\^JaJ hP=h3CJOJQJ^JaJhP=h3CJOJQJ^J)hP=h3B*CJOJQJ^JaJph0jhP=h2BCJOJQJU^JmHnHu)hwUh[VB*CJOJQJ^JaJph hwUh2BCJOJQJ^JaJ .0\^ststIJ\]-.  !!"!#!D!X!gdgdvgd3046JͿͿͿͿ~lUC#h:U}h:U}>*CJOJQJ^JaJ,jh:U}h:U}>*CJOJQJU^JaJ#h[hv5CJOJQJ^JaJ hP=h[VCJOJQJ^JaJ/j;gh:U}h;QCJOJQJU^JaJ/jfh:U}h;QCJOJQJU^JaJh:U}CJOJQJ^JaJ#jh:U}CJOJQJU^JaJhvCJOJQJ^JaJ#hvh[V5CJOJQJ^JaJJLNXZ\^~ϳϢhV*CJOJQJU^JaJmHnHu2j)hhP=h>*CJOJQJU^JaJ#hP=h3>*CJOJQJ^JaJ,jhP=h3>*CJOJQJU^JaJ#hP=h35CJOJQJ^JaJ hP=h3CJOJQJ^JaJ hP=h[VCJOJQJ^JaJ7jh:U}h:U}>*CJOJQJU^JaJmHnHu,jh:U}h:U}>*CJOJQJU^JaJ2jgh:U}h;Q>*CJOJQJU^JaJ p鴚m\N\N=\ hP=h[CJOJQJ^JaJhvCJOJQJ^JaJ h2Bh3CJOJQJ^JaJ&hP=h35CJOJQJ\^JaJ1jhGD>*CJOJQJU^JaJmHnHu2jhhP=h>*CJOJQJU^JaJ#hP=h3>*CJOJQJ^JaJ#hP=h35CJOJQJ^JaJ hP=h3CJOJQJ^JaJ,jhP=h3>*CJOJQJU^JaJpwx er   !!!W!X!Y!Z!]!ƵƊy۵۵hWLHh\ah2h\aB*ph hP=hCJOJQJ^JaJ h2BhCJOJQJ^JaJ h2Bh2BCJOJQJ^JaJ$h2Bh[V0JCJOJQJ^JaJ/jih2Bh[VCJOJQJU^JaJ h2Bh[VCJOJQJ^JaJ)jh2Bh[VCJOJQJU^JaJ h2Bh3CJOJQJ^JaJ&h2Bh36CJOJQJ]^JaJX!Y!Z![!\!]!!!!!!gd3gd  ]!!!!! hP=hCJOJQJ^JaJhIjh\ahvh\aCJOJQJ^J<0&P1F0:pP== /!"#$% tDText1DyK sswapp@email.smith.eduyK Tmailto:sswapp@email.smith.eduyX;H,]ą'cvDeCheck49vDeCheck50vDeCheck51vDeCheck52vDeCheck53tDText2tDText3tDText4xDText199xDText201xDText202xDText203xDText204tDText5tDText6tDText7tDText8tDText5tDText6tDText7tDText8tDText9tDText9jDtDText9tDText9jDtDText9tDText9jDvDText19vDeCheck37vDeCheck38tDeCheck3tDeCheck4tDeCheck5tDeCheck6vDText28xDText205xDText206xDText207jDjDvDeCheck14vDText38vDeCheck15vDText39vDeCheck16vDText40vDeCheck17vDeCheck18vDText42vDText41vDeCheck19vDeCheck20vDText43vDeCheck36vDeCheck21vDeCheck22vDText44xDText208vDeCheck39vDeCheck40vDText45vDeCheck41vDeCheck42$$If!vh5 55555 #v #v#v#v :Vl t<05 555 / / / / vDText53vDText59vDText65vDText66vDText67vDText68vDText69vDText70vDText71$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kdy$$$Ifl ` H h"/ HHHHHH t0<0$$$$44 lavDText54vDText60vDText72vDText73vDText74vDText75vDText76vDText77vDText78$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kd+$$Ifl ` H h"/ HHHHHH t0<0$$$$44 lavDText55vDText61vDText79vDText80vDText81vDText82vDText83vDText84vDText85$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kd2$$Ifl ` H h"/ HHHHHH t0<0$$$$44 lavDText56vDText62vDText86vDText89vDText92vDText95vDText98xDText101xDText104$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kd9$$Ifl ` H h"/ HHHHHH t0<0$$$$44 lavDText57vDText63vDText87vDText90vDText93vDText96vDText99xDText102xDText105$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kd@$$Ifl ` H h"/ HHHHHH t0<0$$$$44 lavDText58vDText64vDText88vDText91vDText94vDText97xDText100xDText103xDText106$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / /  / /  /  kdG$$Ifl ` H h"/ HHHHHH  t0<0$$$$44 laR$$If!vh5<0#v<0:Vl t<05<0/  xDText107xDText109xDText111xDText113xDText115xDText117xDText119xDText121xDText123$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kd1O$$Ifl ` H h"/ HHHHHH t0<0$$$$44 laxDText108xDText110xDText112xDText114xDText116xDText118xDText120xDText122xDText124$$If!v h5 55H5H5H5H5H5H5  #v #v#vH#v :Vl t<05 55H5  / / / /  kdLV$$Ifl ` H h"/ HHHHHH t0<0$$$$44 laxDText126xDText137vDeCheck43vDeCheck44xDText139w$$If!vh555 #v#v#v :Vl t65 5J5)xDText187xDText188xDText209w$$If!vh555 #v#v#v :Vl t65 5J5)xDText189xDText188xDText209w$$If!vh555 #v#v#v :Vl t65 5J5)xDText191xDText188xDText209w$$If!vh555 #v#v#v :Vl t65 5J5)xDText193xDText188xDText209w$$If!vh555 #v#v#v :Vl t65 5J5)vDText52vDeCheck32vDeCheck33vDeCheck45vDeCheck46DyK sswapp@email.smith.eduyK Tmailto:sswapp@email.smith.eduyX;H,]ą'cvDeCheck47vDeCheck48xDText210xDText197xDText198DyK sswapp@email.smith.eduyK <mailto:sswapp@email.smith.edu@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No ListHH ;"c Balloon TextCJOJQJ^JaJj@j Ij Table Grid7:V06U@6 3 Hyperlink >*B*phJB@"J 3 Body Text5B*CJOJQJ\ph01(J014(J 6ij<=| }  . / ^ _ ` a 9 t u = > ? 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