Field Practicum Legal Disclosure Form
Legal Disclosure must be completed for every semester in field practicum
Name
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First Name
Last Name
W#
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WNMU Student ID
Select your Course
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Please Select
SWK492
SWK499
SWK581
SWK582
SWK681
SWK682
Select Semester
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Please Select
Spring
Summer
Fall
Year
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Please enter 4-digit Year requested
WNMU Email
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example@wnmu.edu
Secondary (non-WNMU) Email
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example@email.com
NOTICE TO FIELD APPLICANTS: The School of Social Work requires students with a prior felony or misdemeanor charges or conviction to inform the Director of Field Education PRIOR TO an interview with a practicum agency. Under New Mexico State Statutes, persons with specific felony convictions are not allowed to work in certain agencies or situations. If a student fails to inform the Director of Field Education of a felony or misdemeanor charge or conviction, the student will be dismissed from the Social Work Program. The student must notify the Director of Field Education IMMEDIATELY if charged with or convicted of a felony or misdemeanor occurring after signing this form. I have read and understand this notice:
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Yes
No
LEGAL STATEMENT: Social workers’ primary concern is always the welfare of a client. If a student has a record of felony conviction, or of a misdemeanor conviction such as domestic violence, child or elder abuse or neglect, substance abuse, or DWI, this may impact a student's suitability to practice professional social work. A student must disclose this fact to the Director of Field Education on the application for a field practicum, and prior to interview with the practicum agency. The student will be asked to supply documentation on the nature of the offense and its disposition. A felony or misdemeanor conviction record will not automatically bar a student from enrollment in field practicum; however, it may impact their options pertaining to practicum agencies. The Director of Field Education will make admissions decisions based on multiple factors including a student's academic record and suitability to practice social work, and will include consideration of legal problems including the nature and date of the offense, disposition, rehabilitation efforts and the relevance of the offense to social work practice. Failure to disclose and/or falsification of information will result in immediate dismissal from field practicum. Have you ever been charged or convicted of any type of misdemeanor or felony, as indicated in the legal statement above? (select one)
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Yes
No
Please give details below, including dates, if you have been charged or convicted of any type of misdemeanor or felony, as indicated in the legal statement above. You are also required to provide legal disposition showing that all conditions of sentencing or court orders have been satisfied. Students currently on probation or students who have current or pending charges of any type are not eligible for a field practicum. (If you selected "NO" above, please enter N/A)
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Please sign. *Your signature indicates that you have read and understand the statement regarding legal issues.
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Some placements may require testing for substance use. Would you be willing to submit to testing for illegal substances at the request of your placement agency? (select one) If you select NO, you are ineligible for field practicums.
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Yes
No
MENTAL HEALTH STATEMENT: Professional self-care is paramount for competent and ethical social work practice. Professional demands, challenging workplace climates, and exposure to trauma warrant that social workers maintain personal and professional health, safety and integrity. Social work organizations, agencies, and educational institutions are encouraged to promote organizational policies, practices, and materials to support social workers' self-care. Changes to the Ethical Principles sections of the Code also took into account that self-care also protects social workers' capacity to support the values of integrity. ETHICAL PRINCIPLE: Social workers behave in a trustworthy manner. Social workers are continually aware of the profession's missions, values, ethical principles, and ethical standards and practice in a manner consistent with them. Social workers should take measures to care for themselves professionally and personally. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated. Please sign. *Your signature indicates that you have read and understand the statement regarding mental health issues.
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ETHICS STATEMENT: I certify that I have read, understand and agree to abide by the values and ethics of Social Work as outlined in the National Association of Social Workers Code of Ethics. (NASW Code of Ethics: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English) Your Signature below indicates that you pledge to uphold the NASW Code of Ethics. Applicant Signature
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ACKNOWLEDGEMENT & ACCEPTANCE: If you do not understand or accept any portion of this application, please discuss your concerns with the WNMU Field Director. Applicant Signature
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Date
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