Submitted by swstaff2@smith.edu on October 28, 2016 - 12:35 Submit no less than three, but preferably five weeks before your event. Sponsoring Organization Are you a Smith College School for Social work faculty or staff member? * Yes No Name * Address * Address Line 2 City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Coordinator * Phone Number * Title of Program * Location of Event * Date of Event Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202220232024 Does your course have additional dates? No Yes Does your course have more than 2 dates? No Yes Additional Event Date (2-day Course) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202220232024 Please list the dates and times your program will meet. I understand that if my program is less than 3 weeks from the date my application is submitted I may be charged an additional $15 fee. * Yes Participant Fee (please enter 0 if your event is free) * $ Course Description * Please provide a short description of the program (a few sentences to a short paragraph) Course Objectives * List at least three measurable goals to be accomplished. "By the end of this program students will be able to _____" (longer courses should average 1 per 3 hours of instruction with a maximum of 6). Course Outline * An outline of content and topics that will be covered in the program. Relevance for Social Workers * Please describe how this training will contribute to the growth of professional competence in social work practice. Methodology * Audiovisual Case Presentation Discussion Groups Lecture Online Course Other... Methodology Other... Online CEC's In addition to the standard application for community CECs, organizations wishing to offer online programs must provide us with the following information: Means of tracking student attendance in the online course (login, chat, etc.) Means of verifying student participation (evaluation, test, etc.) Outline method of course presentation (PowerPoint, film, chat, online readings, etc.) Additional Information Instructional Hours(Exclude registration, lunch, coffee breaks, etc. --please fill out both the hour and minutes fields) Time Session Begins * Hour Hour123456789101112 : Minute Minute000510152025303540455055 am pm Time Session Ends * Hour Hour123456789101112 : Minute Minute000510152025303540455055 am pm Total Instructional Hours * Instructor #1 Qualifications Name * Degree (Please include the year the degree was received) * Current Position * Relevant Experience * Instructor CV Files must be less than 100 MB.Allowed file types: pdf doc docx. Instructor #2 Qualifications (click to expand) Name Degree (Please include the year the degree was received) Current Position Relevant Experience Instructor CV Files must be less than 100 MB.Allowed file types: pdf doc docx. Instructor #3 Qualifications (click to expand) Name Degree (Please include the year the degree was received) Current Position Relevant Experience Instructor CV Files must be less than 100 MB.Allowed file types: pdf doc docx. If Instructor is not a licensed social worker, psychiatrist, psychologist, mental health counselor, marriage and family therapist, psychiatric nurse practitioner or other licensed mental health practitioner, please provide the qualifications of the liscensed individual responsible form the planning, development, and review of this content. Bibliography (List relevant books or articles to be distributed; minimum 1 per hour of instruction up to ten hours. A majority of the references must be less than 5 years old.) Or Upload Bibliography Files must be less than 25 MB.Allowed file types: pdf doc docx. In order to receive the CEs your participants must complete 3 assessment questions (they must get 2/3 correct). Please provide your 3 assessment questions either in the field below or as an attachment. Upload Assessment Questions Files must be less than 25 MB.Allowed file types: pdf doc docx. Evaluation Form Files must be less than 25 MB.Allowed file types: pdf doc docx. Person to contact for additional information and notification of approval/disapproval Name * Title Telephone * Mailing Address * Email for Notification * Application Fee: $45.00 if your program does not charge a participant fee. For programs charging participant fees, the application fee is equivalent to the registration fee collected from the first 10 registrations not to exceed $150.00. This amount will be automatically calculated when you submit the form on the following page. Office of Professional Education Smith College School for Social Work, Lilly Hall Northampton, MA 01063 Payment must be received before an authorization number will be issued. *The School has a commitment to ensuring professional training opportunities to professionals working in all communities. Please contact sswpe@smith.edu to discuss options if the fee listed is prohibitive. How would you like to pay? * Credit Card (you will be charged on pressing the "Submit" button below.) Check, payable to Smith College
