Membership Application 18-19
Contact Information
School Social Work Directory
Name *
Your answer
Email Address *
Your answer
School District/Organization *
Your answer
Phone Contact *
Your answer
SSWAN Data Collection
What is the title of your position?
Your answer
Your answer
What is the level of your Licensure/Certification? *
Please select all that apply.
What are the primary functions of your position?
Your answer
What buildings do you serve?
Please list them by name.
Your answer
What is the length of your contract?
Your answer
Are you a certified or non-certified employee?
What level of students do you serve?
Check all that apply.
How many School Social Workers are employed in your district?
Your answer
Are you currently serving a practicum student in your district?
If so, what level?
Your answer
Would you be willing to provide Supervision for Licensure?
What Committee would you be interested in joining?
Method of Payment
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