APPLICATION FOR REGISTRATION PART I

Transcription

1 APPLICATION FOR REGISTRATION PART I Category of Registration: Practicing (employed full-time, part-time, casual or volunteer) Non-Practicing (unemployed, leave of absence, long-term disability, residing in another jurisdiction) PERSONAL INFORMATION: Legal First Name: Legal Last Name: Previous Name: Date of Birth (M/D/YR): Home Address: City: Prov: Postal Code: Primary Telephone: Secondary Telephone: Primary Address: First Language: Other Languages: VOLUNTARY SELF-DECLARATION: The following information is gathered to assist the College in collecting data for statistical purposes and in promoting diversity of membership on MCSW Committees. Completion is voluntary. Please check all that apply: Female Male Other Gender Identity First Nations Inuit Metis Visible Minority Newcomer Member of LGBTQ Community Person with a Disability Other, please specify: EDUCATION INFORMATION: Name of Educational Institution Type of degree/diploma/certificate Year awarded _ Name printed on degree/diploma/certificate: _ of 5

2 EMPLOYMENT INFORMATION: Present Employer: Current Supervisor: Current Supervisor s Address: Applicant s Position Title: Start Date in this Position: Business Address: City: Prov: Postal Code: Business Telephone: _ Business Fax: Employment Region: Northern Western Interlake-Eastern Southern Capital FIVE-YEAR HISTORY OF EMPLOYMENT: (beginning with the most recent) Name of employer: Date From: Date To: If there are any gaps in your professional history, please explain: (Add separate sheet if necessary) PRACTICE INFORMATION: What is your primary field of practice? Addictions Services Adoption Services Adult Mental Health Child/Adolescent Mental Health Child Protection Community Development/Advocacy Corrections/Justice Counselling/Assessment Disability Services Domestic Violence Services Employment & Income Assistance Geriatrics Home-Care/Community Health Services Hospital Social Work Newcomer Services Program Management/Development Research School Social Work Social Policy Social Work Education Victim Services Other: of 5

3 PROFESSIONAL REFERENCE: (Please see attached for Reference Requirements.) Name: Organization: Title: Address: City: Prov: Postal Code: Business Telephone: Business Fax: Business REGULATORY MEMBERSHIP: 1. Have you previously been a member of the Manitoba Institute of Registered Social Workers? 2. Are you now or have you been a registered, licensed or certified member of any other professional regulatory body? If yes, name of Regulatory Body: PROFESSIONAL DECLARATION: (complete in full) If you answer YES to any of the following, please attach a separate sheet with an explanation, as well as any supporting documentation. A positive response to any of these questions will not automatically disqualify an applicant from registration. Are you or have you been the subject of an investigation or proceeding relating to your ethical/professional conduct or suitability to practice social work in Canada or elsewhere? Are you or have you been the subject of an evaluation or disciplinary action due to concerns regarding your professional conduct (i.e. verbal reprimand/warning, disciplinary letter, suspension, etc.)? Are you or have you been the subject of a finding of conduct unbecoming or professional misconduct/incompetence? Have you been involuntarily terminated from any social work or related employment/contract/volunteer work due to concerns regarding your professional conduct? Have you surrendered or cancelled a license, certificate or registration by the issuing authority of any occupation or profession in Canada or elsewhere? Have you been denied registration to practice in social work or any other profession in Canada or elsewhere? Have you been convicted or pled guilty to a criminal offense, or to any other offense under a federal or provincial statute, other than a minor traffic violation? of 5

4 Are you the subject of a current criminal investigation and/or do you have any outstanding charges, other than those related to a minor traffic violation that may be relevant to your suitability to practice social work? Do you or have you had an emotional, physical/mental health or addiction issue that has or may have compromised your professional practice? Do you have any personal or professional conditions that may create a risk to the public? I declare that: If approved for registration I agree to adhere to the Social Work Profession Act and the related Regulation and Bylaw. If approved for registration I agree to adhere to the Manitoba College of Social Workers Standards of Practice and the Manitoba College of Social Workers Code of Ethics. If approved I agree to adhere to the requirements of the MCSW Continuing Competence Program I currently carry or agree to obtain Professional Liability Insurance (purchased independently or through my employer) at a minimum value of $2,000,000 for each position in which I function as a social worker (Practicing registrants only) I agree to notify the College in writing immediately of any changes to any information provided on this application. The information and documentation provided for the purpose of applying for registration with the College is accurate. I understand false or misleading statements, representations or declarations relating to this application for registration are cause for denial or revocation of registration with the Manitoba College of Social Workers. I authorize the College to contact any authority, institution, association, corporation, body or person in any jurisdiction to verify the information provided in this application. I authorize any such authority, institution, association, corporation, body or person to release to the College any information relevant to this application. I authorize the College to include my highest verified social work university degree on the public registry of Social Workers of 5

5 I am legally entitled to work in Canada Canadian Citizen Permanent Resident Work Permit Please Note: The Manitoba College of Social Workers is required to maintain a public registry including registrants names, business addresses, business telephone numbers and names of registrants employers or businesses. Signature of Applicant _ Date NOTE: Please enclose a $ application fee, which is non-refundable, and send with completed application form to: Manitoba College of Social Workers, Portage Avenue, Winnipeg, MB R3J 0K6 Phone: (204) Fax: (204) admin@mcsw.ca Website: of 5

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