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Return this form and supporting documents via email to: Sarah S. Andrews  HYPERLINK "mailto:ssb4@case.edu" ssb4@case.edu Director of School Social Work, Jack, Joseph, and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, 11235 Bellflower Road, Cleveland, Ohio 44106-7164. (PLEASE PRINT) Applicant:_____________________________________________________________ Address:______________________________________________________________________ Phone:_______________________________ E-Mail:_______________________________ Date Submitted:_________________________ ( MSASS Graduate (include copy of transcript) Year graduated________________ Non MSASS Graduate: Social Work Program __________________ Year graduated _________ (Please include a transcript) Children, Youth, and Families Specialization School Social Work Specialization Other Concentration or Specialization (please specify) __________________________________________________ Field Placement completed (indicate school district and year)________________________________ One year social work experience in school (please name school and district)______________________________________ Year(s)______________________ Ohio LISW or LSW (provide copy) Post Master's Course Work/Training (Please list) ________________________________________ ________________________________________________________________________ Please also include a current resume or C.V.  For Mandel School Use: After reviewing your materials, it has been determined that the following needs to be completed: SASS 519: Children and Families in the School Setting (MSASS course), offered fall semester on campus EDU 510 Educational Studies (BW course) offered summer online EDU 573 Education of Children with Special Needs (BW course) offered fall, spring, and summer online EDU 584 Pupil Services & Community Resources (B-W course), offered summer online Other:_______________________________________________________________________________________________________________________________________________ Date reviewed: ________________________Date mailed to applicant ________________________________ Signed: ___________________________________________________________________________________ ghnxy{����� 8 B V W X z { � � � � �  % 7 W h i z � � � � � �  1 N _ q � � � � � �  & Q X s  � � ýֹֹֹ֤ЗннАннн hJeE5CJ jq�hJeECJho�hqq\h+d hb�0Jjhb�Uhb� hqq\CJ ho�CJ hJeE>*CJ hJeECJhJeEhb�5�:CJho�5�:CJhJeE5�:CJhb�5�:CJaJ8hz{T U � � > g h �  ����������nn- �80�h��p� @ ��P ��!��dh^�`�gdJeE* �80�h��p� @ ��P ��!��^�`�gdJeE-$ �80�h��p� @ ��P ��!��^�`�a$gdJeE �^`�gdJeE  0 ^ � H � � � S�������~��~- �80�h��p� @ ��P ��!h�dh^h`�gdJeE' & F �50���p� @ ��P ��!dhgdJeE- �80�h��p� @ ��P ��!��dh^�`�gdJeE � � � (���������GJNOP|���������������*JRS�����b������ſſſſſŹŰſſſſſhV�h��hJeECJaJ hb�CJho�ho�CJho�hJeECJ hqq\CJ ho�CJ hJeECJ hJeE5CJ!jh��CJUhmHnHuhqq\hJeE5CJ hqq\5CJ hqq\CJ hJeECJ4�����EF��S�;�����������������' & F �50���p� @ ��P ��!dhgdJeE- �80�h��p� @ ��P ��!��dh^�`�gdJeE* �80�h��p� @ ��P ��!��^�`�gdJeE���.:pJeE/ =!"#�8$�8%� w���������666666666vvvvvvvvv666666>666666666666666666666666666�6666666666�666666666666hH66666666666666666666666666666666666666666666666666666666666666666�62���� 0@P`p�����2(�� 0@P`p����� 0@P`p����� 0@P`p����� 0@P`p����� 0@P`p����� 0@P`p�8X�V~������� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@6666 OJPJQJ_HmH nH sH tH T`�T JeENormalp^p`�OJPJQJ_HmH sH tH DA ��D Default Paragraph FontRi��R 0 Table Normal�4� l4�a� (k ��( 0No List lo��l JeE 1AutoList1 ���0^`�0�#CJOJPJQJ_HhmH sH tH 6U`�6 qq\0 Hyperlink >*B*ph�Rv!�R b�0Unresolved MentionB*ph`^\q� ��PK!�[Content_Types].xmlN�0EH�-J@%ǎǢ|�$زULTB� l,�3;r�ØJB+$�G]7O٭VGRU1a$N%� ʣꂣKЛjVkUDRKQj/dR�*SxMPsʧJ5�$4vq^W�Cʽ D{>̳`�3R�EB�=�꽻Ut� Qy@֐\.X�7<:+& �0h� �@�>n�ƭB�Vqu�� �ѡ{�5�kP�?O&C� Aw0kPo۵�(h[�5(�$=CVs]mY2zw`nKDC]j�%KXK� �'P@�$I=Y�%C%gx'$�!V(ekڤ���'Qt!x�7xbJ7 o߼W_y|n�;Fido��/_�1z/L?>o����_;9:3�3`�=—S�,FĔ觑@)R�8el�mE�v|�!ո/,Ә%qh|'1:`ij.̳u�'k�� CZ^WcK�0��'�E8S߱s��ˮdΙ`K}A�"NșM1I�/AeހQתGF@A~eh-QR9C 5 ~d�"9 0exp�<^!͸~J7䒜t� L�c\�)Ic8�E�&]Sf��~@Aw?'r3Ȱ&�2@�7k}̬n�aWJ}N1XGVh`L�%Z`�=`VK�b�*X�=�z%�"�sI<�&�n| �.qc:?7/N�<Z�*`]u�-�]e|aѸ¾|mH{m3CԚ� ��.ÕnAr)�[;-�ݑ$$`�:�>NVl%kv:Ns� _Ou�CX�=mO�4m's߸d|�0n;pt2e�}�:zOrgI( �'B��='8\L`�"Ǚ 4F+8JI$rՑVL�vVxNN�";fVYx-,JfV�<�+k>h�P!aLfh:HHX WQXt,:JU{,Z�� BpB�)sֻ�ӇiE4(=U\.O�. �+x�"aMB[F7x"ytѫиK-z�z>F>7�5�eo5C�9Z%c��7�ܼ�%�6M2ˊ 9B"� N� "1�(IzZ~���>Yr]H+�9pd\4n�(Kg\V�$��=�]B,lוDA=eX�)Ly�5ot e㈮bW3gp :� j�$/g�*QjZTa!e9#i�5*j�5ö fE`�51�4g{7vnO(�^� �,j~V9;kv�v�"adV݊oTAn7jah+y^@�ARhW.G�MuO �"/e�5[s󿬅`�Z'WfPt~f}kA�'�0z|>ܙ|Uw{@՘tAm�'`4T֠2j ۣhvWwA�9 ZNU+Awvhv�3�6V`^���PK! 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 72 Fx0 EDU 510 Educational Studies (  2 F  0 BW course)   "2 Fd0 offered summer   2 F�0   2 F�0 online   2 F�0    2 F�0    0'��'��- - - - - - - - -   2 ]`0 q ---  2 ]l0  - - -  %2 ]x0 EDU 573 Education   2 ]�0    2 ]�0 o 72 ]�0 f Children with Special Needs    2 ]�0   2 ]� 0 (BW course)   ;2 ]� 0 offered fall, spring, and summer   2 ]�0   2 ]�0 online   2 ]�0    0'��'��- - - ---- - - ---- - - - - -   2 v`0 q ---  2 vl0  --- M2 vx,0 EDU 584 Pupil Services & Community Resources      - - -   2 v�0   2 v�0 (B  2 v�0 -  2 v�0 W   2 v�0   2 v�0 course %2 v�0 ), offered summer   2 vG0   2 vL0 on 2 vZ0 line   2 vq0    0'��'��- - - - - - - - -   2 �`0 q ---  2 �l0  - - -  �2 �xZ0 Other:____________________________________________________________________________________   0'��'��  2 �x0 _ b2 �:0 __________________________________________________________  2 �0    0'��'�� F2 �`'0 Date reviewed: ________________________   b2 �X:0 Date mailed to applicant ________________________________    2 ��0    0'��'�� _2 �`80 Signed: ________________________________________________ >2 ��"0 __________________________________  2 ��0 _  2 ��0    0'��'���-�-8a�����a�a�a�����a�a�-�-�'����"System&�GS�` �)�r--  00//..� ՜.+,D՜.+,H hp���� ���� � �� Case Western Reserve University�   Title� 8@ _PID_HLINKS�AdW'mailto:ssb4@case.edu ������ !"#$%&'(���*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWX���Z[\]^_`������c�����������������������������������������������������������������������������������������������������������������Root Entry�������� �FMY�"�eData ������������1Table����Z WordDocument����0SummaryInformation(������������)_DocumentSummaryInformation8��������YCompObj������������r���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ���� �F Microsoft Word 97-2003 Document MSWordDocWord.Document.8�9q