School Social Worker Certificate Program Application

Matriculated MSS Student and MSS Alumnae/i Application

Note: This form will not save while you work on it. If you close this page and come back, your answers will not be saved.

APPLICANT INFORMATION

Full Name *

Email Address *

Phone Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Birthdate * +

I am... *

a current MSS student.

an incoming MSS student.

a MSS alumnae/i.

For MSS Alumnae/i, do you currently have a LSW (or LCSW) license?
(Note: For PDE Certification, you will be required to have a PA LSW (or LCSW.)

Yes

No

FIELD PLACEMENT
Are you currently (or planning to be) in a Field Placement in a school-based setting when enrolled in the School Social Worker Certificate program? *

Yes

No

I am not certain and would like to discuss further.

If you answered yes, tell us about your Field Placement (School Name, Start/End Term, Supervisor (if known), Supervisor Credentials (if known).
If you answered no, tell us about how you intend to satisfy the field education requirement.

EMPLOYMENT

MSS Alumnae/i must complete this section.

Current MSS students who are using their current employer as their field placement must complete this section.

Do you intend to use your current employment for the school-based field practicum requirement?
NOTE: SSWC requires field practicum be in a PK-12 school-based setting.

Yes

No

I am unsure.

If you answered yes to the above question, please email your job description that includes details of your responsiblities to swprodev@brynmawr.edu

If yes, tell us about your supervisor. Does your supervisor hold one of the following credentials?

PA Licensed Social Worker (LSW)

PA Licensed Clinical Social Worker (LCSW)

PA Home and School Visitor Educational Specialist Certification (HSV)

PA School Social Worker Educational Specialist Certification (SSW)

None of the above.

Current Employer

Current Position

Direct Supervisor Name

Current Employment Email

Current Employer Street Address

Current Employer Address Line 2

Current Employer City

Current Employer State

Current Employer Zip Code

How did you learn about the Bryn Mawr College School Social Worker Certificate Program?

Colleague	Supervisor
Field Education Office	Fellow Student
Academic Advisor	Admissions
Internet Search	Friend
Family	Social Media
None of the above