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Smith College Studies in Social Work
Continuing Education Programs

Advanced Clinical Supervision Application

The Application form below will open an application with the School for Social Work. Please be sure to submit the following materials by mail or email (sswced@smith.edu): resume, personal statement, 2 reference letters.

First name:
Last name:
Social work license number:
Years of post-masters clinical experience:
Years of post-masters clinical supervisory experience:
Are you an SCSSW alumna/us?
- degree/year?
Are you a 2012-13 or 2013-14 SSW field affiliate?
E-mail:
Home address:
City:
State:
Zip code:
Home telephone: ( )
Place of employment:
Business address:
City:
State:
Zip code:
Work telephone: () -
Fax number: () -
College (highest degree received):
Degree/major/year:
Have you previously taken continuing education courses through Smith?
How did you hear about this program?

Optional Information

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. (Optional information, not required for consideration of application.)

A.) Are you Hispanic or Latina/o? No
Yes, Hispanic or Latina/o (including Spain)

Please describe your background:

B.) Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native (including all Original Peoples of the Americas)
Please describe your background:
Are you enrolled? No Yes / Tribal Enrollment Number

Asian (including Indian subcontinent and Philippines)
Please describe your background:

Black or African American
Please describe your background:

Native Hawaiian or Other Pacific Islander (Original Peoples)
Please describe your background:

 White (including Middle Eastern)

Which best describes your background? European
Middle Eastern
Other

Other

Payment

*Indicates required information

Please charge my nonrefundable $40 application fee to:* Visa MC
Account number:*
Exp. month:*
Exp. year:*
Billing first name:*
Billing last name:*
Billing e-mail:*
Billing street:*
Billing city:*
Billing state:*
Billing zip code:*
Billing country:*

By submitting this form, I confirm my application to the Advanced Clinical Supervision Certificate Program.

If you are unable to use this form, e-mail us at the Smith College School for Social Work Office of Continuing Education, or call us at (413) 585-7970.

Accreditation: The Smith College School for Social Work is accredited by the Council on Social Work Education. Courses offered through the school's Program of Continuing Education are awarded continuing education credit in accordance with Continuing Education Regulations of the Commonwealth of Massachusetts.