1 S A Council for Social Service Professions SACSSP Private Bag X12, Gezina, 0031 Tel: (012) 356 8333 Email: [email protected] Inq: Customer care 37 Annie Botha Ave, Riviera, Pretoria, 0084 Fax: (012) 356 8400 Website: www.sacssp.co.za Ref: APPLICATION FOR REGISTRATION AS A STUDENT SOCIAL WORKER THIS APPLICATION FORM MUST BE COMPLETED ONLY BY STUDENT SOCIAL WORKERS WHO APPLY TO REGISTER WITH COUNCIL FOR THE FIRST TIME. PLEASE PRINT OR TYPE. Study the application form carefully before completing it. Answer all questions fully, clearly and correctly. Questions which do not apply to you, must be clearly deleted. Should you have to make any corrections to your answers, initial them in the margin. PLEASE NOTE: To avoid delay of your registration, your proof of payment and the requested documents as listed on page two MUST accompany this application form. 1. PERSONAL PARTICULARS 1.1 Title: 1.2 Prof 1.3 Surname: Maiden name: 1.4 Full first names: Dr Rev Mr Mrs Ms (Additional initials, not including the already mentioned names) 1.5 Registration number as student social worker (For office use only) 40 - 2 2. PLEASE NOTE: This application form must be completed by all students who apply for the first time for registration as a student social worker with the S A Council for Social Service Professions and who during the academic year to which this application refers, will undergo field instruction or experiential learning as part of the course in the subject Social Work. PLEASE NOTE: Any student who has abandoned his/her studies for longer than THREE years, will have to apply anew for registration and again pay the prescribed registration fee 3 Your application must reach the Council before or on 31 March of the academic year to which this application refers and must be accompanied by the following: 3.1 A certified copy of your identity document (the photo page). 3.2 A certified copy of the marriage certificate of a person who is married. 3.3 A certified copy of the divorce decree if a person is divorced. 3.4 The original academic record issued by the training institution concerned, in which an indication is given of all the subjects or modules and the year course/level in each subject or module you have already passed and the subjects or modules and year course in each subject or modules for which you are enrolled in the year of application. 3.5 A bank deposit slip or electronic transfer payment slip as proof of payment to the value of the prescribed registration fee. 4. Address your application to the Registrar, S A Council for Social Service Professions, Private Bag X12, Hatfield, Pretoria, 0031. 5. REGISTRATION PARTICULARS 5.1 Have you previously applied for registration as a student social worker, social auxiliary worker or social worker in the RSA? 5.2 5.3 5.4 5.5 (a) student social worker: Yes  No  (b) social auxiliary worker: Yes  No  (c) social worker Yes  No  If yes, what was the result? Approved  Rejected  Incomplete Registration number allocated to you: (if any)  - Identity number: Date of birth: Y M D  -  -  (Attach a certified copy of acceptable documentary proof of your names, identity number and date of birth or age) 5.6 Gender: 5.7 Population group 1. Male 2. Female 1. White 2. Coloured 3. Black 4. Indian 5. Other 3 5.8 Marital status 1. Never married 2. Married 3. Divorced 4. Widow/Widower (Women who are married, must attach a certified copy of their identity document in the marriage surname and/or marriage certificate) 5.9 Physical residential address (e.g. home where you originally reside): Postal code 5.10 Postal address (where correspondence will reach you during training): Postal code 5.11 Tel. no.: code ……………no ……………………… Cell No.: . ………. ……………............... Email address: ………………………………………………………………………………………………… 6. TRAINING INSTITUTION WHERE YOU ARE ENROLLED FOR THE ACADEMIC YEAR TO WHICH THIS APPLICATION REFERS: 6.1 Name of training institution: 6.1.1 University: 1 UDW 2 UCT 6 NMMU 7 UNIV. OF NORTH WEST (POTCH CAMPUS) 12 UNISA 11 US 16 UNIV. OF THE NORTH WEST (MAFIKEN CAMPUS) 17 FORT HARE 3 UKZN/ NATAL 8 UP 4 LIMPOPO 13 UWC 14 WITS 15 Z-LAND 18 WALTER SISULU UNIV. 19 VENDA 20 HUGUENOT COLLEGE 9 UJ 5 UFS 10 RHODES 4 22. 6.1.2 Other: 7. ACADEMIC PARTICULARS WHICH APPLY TO THE ACADEMIC YEAR TO WHICH THIS APPLICATION REFERS: 7.1 Qualification in Social Work for which you are enrolled: 7.1.1 Qualification 1. Basic Degree 7.1.2 Duration of course 7.1.3 2. Diploma 1 year 3. SW Certificate (NDP) 2 years 4. Honors Degree 3 years 5. Post Graduate Certificate 4 years Date on which you initially registered with the training institution as a student for this qualification: Y M D  -  -  7.1.4 Name of qualification: (Eg B (SW); BSoc.Sc.; etc. 7.2 Year course/level for which you are enrolled in the subject Social Work: ACADEMIC YEAR 20 8. YEAR COURSE 2nd 3rd 4th 5 Advanced ACADEMIC PARTICULARS OF QUALIFICATIONS ALREADY OBTAINED (IF ANY)* Qualification Training institution Date conferred 8.1 8.2 8.3 * PLEASE NOTE: Certified copies of documentary proof of the qualifications referred to in point 8 must be attached in order to be entered into the Register. If a qualification has not yet been conferred upon you, you must attach a document, acceptable to the Council, issued by a person acting on the authority of the training institution, certifying that the qualification will be conferred upon you and on a certain date. 5 9. GENERAL QUESTIONS Please make a cross on either yes or no: 9.1 Have you ever been found guilty of unprofessional conduct by the Council? 9.2 Have you ever been found guilty of an offence by a court of law? 9.2.1 If the answer is yes, specify the nature of the offence of which you were convicted, the year in which it took place and the sentence passed: 9.3 Are any legal steps pending against you at present? 9.3.1 If yes, specify: Yes No Yes No I, the undersigned, declare that the information furnished in this application form is true and correct in all respects and that I am unaware of anything which would serve as an impediment to the registration of my name as a student social worker to the Register for Student Social Workers. Signed at ……………………………………………………………………………. on this ………………….day of ………………………………………………………………………. ……………20…………………………… SIGNATURE OF APPLICANT