Submitted by email@example.com on February 15, 2017 - 09:41 1 Start 2 Preview 3 Complete Application Fee (payable by credit card): $40.00 Online Application The Application form below will open an application with the School for Social Work. Please be sure to submit the following materials by online form, mail or email (firstname.lastname@example.org): resume, personal statement, 2 reference letters. First Name: * Last Name: * Social Work License Number: Social Work License State: Social Work License Type: Years of post-masters clinical experience: Are you an SCSSW alumna/us? No Yes What year did you receive your degree? Are you a 2018-19 or 2019-20 SSW field affiliate? No Yes Field Affiliate Agreement By initialing below, I acknowledge that, as a Smith Supervisor, I understand that I am receiving a tuition discount to attend this program ($500 vs. $2,400). If, however, I fail to complete the program, I will be charged the full tuition for the program. * Personal Information E-mail: * Home address: * City: * State: * Zip code: * Home telephone: Employment Information Place of employment: Business address: City: State: Zip code: Business telephone: Fax number: Education College (highest degree received): Degree/major/year: Have you previously taken continuing education courses through Smith? No Yes How did you hear about this program? Optional Information Smith College seeks students of all racial and ethnic groups. If you wish to identify yourself as a member of a racial or ethnic group, please indicate below. If applicable, you may check more than one box. We invite you to be specific. (Optional information, not required for consideration of application.) A.) Are you Hispanic or Latinx? No Yes, Hispanic or Latinx (including Spain) Please describe your background: B.) Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself a member: American Indian or Alaska Native (including all Original Peoples of the Americas) Asian (including Indian subcontinent and Philippines) Black or African American Native Hawaiian or Other Pacific Islander (Original Peoples) White (including Middle Eastern) Other... B.) Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself a member: Other... Which best describes your background? -Select-EuropeanMiddle EasternOther... Which best describes your background? Other... Please describe your background: AccessibilityIf you are unable to use this form, e-mail us at the Smith College School for Social Work Office of Continuing Education, or call us at (413) 585-7970. By submitting this form, I confirm my application to the Certificate Program for Palliative and End-of-Life Care. Note: you will be charged the $40 application fee on the next page.