S A Council for Social Service Professions SACSSP

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