MSW-DCF Child Welfare Stipend Internship Program DCF Child Welfare Stipend Internship Application ContactName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) UConn Student ID#(Required) Which Area Office/Facility are you interested in being matched with (check all that apply)?(Required) Bridgeport Norwalk Milford New Haven Middletown Norwich Willimantic Hartford Manchester Danbury Torrington Waterbury Meriden New Britain Please Answer the Following QuestionsWhat is your anticipated graduation date (month/year)?(Required) Did you complete a class in Child Welfare in the past year?(Required) Yes No Course Name & Code(Required) Do you agree to enroll in the required course in the coming fall or spring semester?(Required) Yes No Do you speak Spanish fluently?(Required) Yes No Do you have a valid driver's license?(Required) Yes No If selected for the stipend program, do you agree to the following? Check yes or no for each.Maintain enrollment for the entire academic year(Required) Yes No Maintain a cumulative GPA of at least 3.0(Required) Yes No Meet the internship program requirements and successfully complete the internship at DCF(Required) Yes No Complete background screening including child protective services, fingerprinting (criminal) and Department of Motor Vehicle(Required) Yes No Meet the internship program requirements and successfully complete the internship at DCF(Required) Yes No Conduct home visits in diverse neighborhoods with diverse families(Required) Yes No Successfully complete the field education program (and) complete all courses and requirements necessary to obtain your MSW degree as outlined by your educational program(Required) Yes No Accept a position for employment at DCF, if offered, and remain employed by DCF for (2) years(Required) Yes No Return or repay $2,000 to DCF if you do not graduate/complete all program requirements OR do not fulfill the employment requirement (either voluntarily or due to termination)(Required) Yes No Notify DCF Academy for Workforce Development in writing within five calendar days of any name or address change until the work commitment or repayment is fulfilled(Required) Yes No Electronic Signature(Required) Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.