Membership Application 20-21
Email address *
Contact Information
School Social Work Directory
Name *
Preferred Email Address (if different from above)
School District/Organization *
Phone Contact *
SSWAN Data Collection
What is the title of your position?
Specializations/Experience
Initiatives in your District and/or community that you are a part of? Programming or curriculum that you helped develop or implement? Other areas that you have received specialized training on or train others on?
Have you ever been a member of SSWAN before? *
Topics of Interest or Speakers/Presentations You Would Recommend?
What is the level of your Licensure/Certification? *
Please select all that apply.
Required
What are the primary functions of your position?
What buildings do you serve?
Please list them by name.
What is the length of your contract?
Are you a certified or non-certified employee?
Clear selection
What level of students do you serve?
Check all that apply.
How many School Social Workers are employed in your district?
Are you currently serving a practicum student in your district?
Clear selection
If so, what level?
Would you be willing to provide Supervision for Licensure?
Clear selection
What Committee would you be interested in joining?
Level of Membership *
Method of Payment
Clear selection
A copy of your responses will be emailed to the address you provided.
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