Registration of interest in providing Field Education placements

Complete the form below, including the names of supervisors, if your agency is interested in providing placements for students.

This form was not completed correctly. Please review the items in red.

Person completing this form

Given name/s *

Surname *

Position/Title

Include me on mailings regarding

Student placement offers

Professional learning opportunities

Agency details

Person to contact for student placements

Given name/s *

Surname *

Preferred name

Gender *

Male

Female

Position in agency *

Direct phone *

Mobile

Fax

E-mail address

Include me on mailings regarding

Student placement offers

Professional learning opportunities

Street Address *

Field educator/Placement supervisor

Given name *

Surname *

Preferred name

Position/Title

Gender *

Male

Female

Position in agency *

Direct phone *

Mobile

Fax

E-mail address

Include me on mailings regarding

Student placement offers

Professional learning opportunities

Mailing address (if different from agency)

Eligible for AASW membership *

Yes

Course Name

Institution

Length of course

Please list your relevant qualifications in Social Work or Humans Services here *

Course Name

Institution

Length of course

Please list your relevant qualifications in Supervision here *

Can you provide placement offer for

3rd year

4th year

Either

Comments and additional information

The University of Sydney - Faculty of Education and Social Work

Person completing this form

Agency details

Person to contact for student placements

Field educator/Placement supervisor