ࡱ> bdaO bjbj@@ 0"e"e FF$^VVV$HLV4"VVVGtttV.tVttLY"v.0^J :J J VVtVVVVV4@VVV^VVVVJ VVVVVVVVVF Q: POST-MSW APPLICATION FOR ASSESSMENT TO WORK TOWARD ELIGIBILITY TO APPLY FOR THE PUPIL SERVICES LICENSE (Rev FEB 2022) First, gather all your supporting documents. Then, please complete the top portion of this application checklist and attach it to your documents. Return this form and supporting documents via email to: Sarah S. Andrews  HYPERLINK "mailto:ssb4@case.edu" ssb4@case.edu Director of School Social Work, Jack, Joseph, and Morton Mandel School of Applied Social Sciences, ǿմý, 11235 Bellflower Road, Cleveland, Ohio 44106-7164. (PLEASE PRINT) Applicant:_____________________________________________________________ Address:______________________________________________________________________ Phone:_______________________________ E-Mail:_______________________________ Date Submitted:_________________________ ( MSASS Graduate (include copy of transcript) Year graduated________________ Non MSASS Graduate: Social Work Program __________________ Year graduated _________ (Please include a transcript) Children, Youth, and Families Specialization School Social Work Specialization Other Concentration or Specialization (please specify) __________________________________________________ Field Placement completed (indicate school district and year)________________________________ One year social work experience in school (please name school and district)______________________________________ Year(s)______________________ Ohio LISW or LSW (provide copy) Post Master's Course Work/Training (Please list) ________________________________________ ________________________________________________________________________ Please also include a current resume or C.V.  For Mandel School Use: After reviewing your materials, it has been determined that the following needs to be completed: SASS 519: Children and Families in the School Setting (MSASS course), offered fall semester on campus EDU 510 Educational Studies (BW course) offered summer online EDU 573 Education of Children with Special Needs (BW course) offered fall, spring, and summer online EDU 584 Pupil Services & Community Resources (B-W course), offered summer online Other:_______________________________________________________________________________________________________________________________________________ Date reviewed: ________________________Date mailed to applicant ________________________________ Signed: ___________________________________________________________________________________ ghnxy{ 8 B V W X z {  % 7 W h i z  1 N _ q  & Q X s  ýֹֹֹ֤ЗннАннн hJeE5CJ jqhJeECJhohqq\h+d hb0JjhbUhb hqq\CJ hoCJ hJeE>*CJ hJeECJhJeEhb5:CJho5:CJhJeE5:CJhb5:CJaJ8hz{T U > g h  nn- 80hp @ P !dh^`gdJeE* 80hp @ P !^`gdJeE-$ 80hp @ P !^`a$gdJeE ^`gdJeE  0 ^ H S~~- 80hp @ P !hdh^h`gdJeE' & F 50p @ P !dhgdJeE- 80hp @ P !dh^`gdJeE (GJNOP|*JRSbſſſſſŹŰſſſſſhVhhJeECJaJ hbCJhohoCJhohJeECJ hqq\CJ hoCJ hJeECJ hJeE5CJ!jhCJUhmHnHuhqq\hJeE5CJ hqq\5CJ hqq\CJ hJeECJ4EFS;' & F 50p @ P !dhgdJeE- 80hp @ P !dh^`gdJeE* 80hp @ P !^`gdJeE.:pJeE/ =!"#8$8% w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666 OJPJQJ_HmH nH sH tH T`T JeENormalp^p`OJPJQJ_HmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List lol JeE 1AutoList1 0^`0#CJOJPJQJ_HhmH sH tH 6U`6 qq\0 Hyperlink >*B*phRv!R b0Unresolved MentionB*ph`^\q PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]     Wz XL# @(  PB  # Ԕ#" ?B S  ? 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Then,    2 0 please  2  0 complete   A2 $0 the top portion of this application @Times New Roman---- @ ! -  0''--------------- 72 `0 checklist and attach it to yo  2 0 ur documents.  --- J2 X*0 Return this form and supporting documents      2 s 0 via email    2 0 to:   0'' #2 `0 Sarah S. Andrews      2 0   2 0 ssb4@case.edu  2 70   ;2 = 0 Director of School Social Work,    12 0 Jack, Joseph, and Morton @Times New Roman---- @ !`-   0''--- g2 `=0 Mandel School of Applied Social Sciences, Case Western Reserv       "2 0 e University, 1   #2 b0 1235 Bellflower      0'' 2 `0 Road,  &2 0 Cleveland, Ohio   2 0 44106  2 '0 - ,2 -0 7164. (PLEASE PRINT)      2 0    0''  2 `0    0''--------- 2 `0 Ap --- s2 sE0 plicant:_____________________________________________________________  2 b0    0'' 2 "`N0 Address:______________________________________________________________________   2 "0    0'' )2 3`0 Phone:______________  /2 30 _________________ E   2 30 - A2 3$0 Mail:_______________________________   2 30    0'' G2 D`(0 Date Submitted:_________________________    2 Dz0    0''  2 T`0    0''@Wingdings- - - ---- - - ---- - -   2 e`0 q ---  2 em0   #2 ex0 MSASS Graduate (    2 e0 include  (2 e0 copy of transcript)  2 e0  + 2 e0 Year   2 e0   2 e 0 graduated #2 e 0 ________________  2 e0    0''------------ 2 `0  --- k2 z@0 Non MSASS Graduate: Social Work Program __________________ Year         2 60   2 90 gra 2 L0 duated  2 s0   2 v 0 _________  2 0    0''  2 `0   72 x0 (Please include a transcript)   2 0    0''@Wingdings- - - @"Arial- - - ---- - -   2 `0 q - - -   2 m0  ---  2 x0 C  72 0 hildren, Youth, and Families    "2 .0 Specialization   2 0    0''- - - ---- - -   2 `0 q - - -   2 m0  ---  2 x0 S &2 0 chool Social Work   2 0 Specialization  2 A0    0''- - - ---- - -   2 `0 q - - -   2 m0  --- 2 x0 Other   2 0   2  0 Concentration   2 0   2 0 or  #2 0 Specialization ( #2 `0 please specify)   0'' V2 x20 __________________________________________________  2 0    0''- - - ---- - -   2 `0 q - - -   2 m0  --- ,2 x0 Field Placement comple    72 0 ted (indicate school district  2 0   2 0 and year =2 !0 )________________________________  2 0    0''- - - ---- - -   2 0`0 q - - -   2 0m0  --- 2 0x 0 One year  2 00 social  42 00 work experience in school (  2 0z 0 please name   2 00 school  2 00   2 00 and   0'' 2 Ix0 district F2 I'0 )______________________________________  2 I0    0'' 82 bx0 Year(s)______________________   2 bK0    0''- - - ---- - -   2 |`0 q - - -   2 |m0  --- 2 |x0 Ohio  22 |0 LISW or LSW (provide copy)    2 |I0    0''- - - ---- - -   2 `0 q - - -   2 m0  --- 2 x0 Post Ma   72 0 ster's Course Work/Training (   2 X 0 Please list  J2 *0 ) ________________________________________  2 0    0'' w2 xH0 ________________________________________________________________________  2 0    0''--- O2 `-0 Please also include a current resume or C.V.      2 {0    0''---  2 `0    0''--- 2 `0 For M  2  0 andel School  2 0 Use:   2 0    0''---  2 `0    0''@Times New Roman- - -  52 `0 After reviewing your materia    q2 D0 ls, it has been determined that the following needs to be completed:     2 c0    0''  2 `0    0''@Wingdings- - - @"Arial---- - - - - -   2 /`0 q ---  2 /l0  - - -   2 /x0 S 2 /0 ASS   2 /0   2 /0 519  2 /0 :  2 /0   M2 /,0 Children and Families in the School Setting   2 /0 (MSASS    2 /0   2 /0 course 2 /0 ),  2 /0 offered  2 /. 0 fall semester   2 /r0   2 /u 0 on campus   2 /0    0''- - - - - - - - -   2 F`0 q ---  2 Fl0  - - -  72 Fx0 EDU 510 Educational Studies (  2 F  0 BW course)   "2 Fd0 offered summer   2 F0   2 F0 online   2 F0    2 F0    0''- - - - - - - - -   2 ]`0 q ---  2 ]l0  - - -  %2 ]x0 EDU 573 Education   2 ]0    2 ]0 o 72 ]0 f Children with Special Needs    2 ]0   2 ] 0 (BW course)   ;2 ] 0 offered fall, spring, and summer   2 ]0   2 ]0 online   2 ]0    0''- - - ---- - - ---- - - - - -   2 v`0 q ---  2 vl0  --- M2 vx,0 EDU 584 Pupil Services & Community Resources      - - -   2 v0   2 v0 (B  2 v0 -  2 v0 W   2 v0   2 v0 course %2 v0 ), offered summer   2 vG0   2 vL0 on 2 vZ0 line   2 vq0    0''- - - - - - - - -   2 `0 q ---  2 l0  - - -  2 xZ0 Other:____________________________________________________________________________________   0''  2 x0 _ b2 :0 __________________________________________________________  2 0    0'' F2 `'0 Date reviewed: ________________________   b2 X:0 Date mailed to applicant ________________________________    2 0    0'' _2 `80 Signed: ________________________________________________ >2 "0 __________________________________  2 0 _  2 0    0''--8aaaaaa--'"System&GS` )r--  00//.. ՜.+,D՜.+,H hp   ǿմý   Title 8@ _PID_HLINKSAdW'mailto:ssb4@case.edu  !"#$%&'(*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`cRoot Entry FMY"eData 1TableZ WordDocument0SummaryInformation()_DocumentSummaryInformation8YCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q