SCSCSW New Membership Application


Please fill in all applicable fields below.

OR... if you prefer, you may download the membership form, print it, and send a copy to Leigh Bostic along with a check made out to "SCSCSW".

Questions?
Contact Membership Chair, Leigh Bostic
Email: membership@scclinicalsocialwork.org
Phone: (864) 430-0475
Fax: (864) 298-8032 - attn: Leigh Bostic

All supporting information should be sent to Leigh Bostic after submitting the form.

First Name:
Last Name:
Work Title/Position:
Organization:
Preferred Email:
Preferred Mailing Address:
City:
State:
Zip:
Phone (work):
Phone (home):


Demographic Information:

Licensed in SC?
SC License #:
Level:
Practice Type:
Other credentials, licenses, and certifications held:
Practice modality or special interests (to be included in membership directory):


Education/Work History:

Describe you current practice and work history:
List agency or setting, dates, position, job description. (or send resumé to Leigh Bostic)
 
Education:
School, address, degrees, year, name on diploma (if different from current name), description of field placement and course sequence. (Send a photocopy of your highest degree diploma to Leigh Bostic.)
 
Supervision: (if applying for FULL membership status)
Describe supervision received: dates, hours per week, and supervisor's name(s), credentials, and business address. (Group or individual?)


Every member is encouraged to serve on a committee. Please indicate interest(s):
Education Finance Public Relations
Ethics Nominations
Government Affairs Membership


Membership Category:
I wish to receive a $15 discount on membership by accepting all SCSCSW correspondence electronically (email and website).
I wish to deduct an additional $35 from my SCSCSW membership fee by sending a current copy of my CSWA membership certificate to Leigh Bostic. (NOTE: If you join or renew with Clinical Social Work Association within the next year, you may submit a copy of the membership certificate at that time and be reimbursed $35.)

Total Membership Cost:


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