Child Welfare Request for Deferral/Exemption of Employment Obligation

UW–Green Bay Child Welfare Education Program

Attachment E

Request for Deferral / Exemption of Employment Obligation

Deferral or exemption of employment obligation: Stipend recipients who:

- are in their Field Practicum placement and feel they are no longer suited for child welfare work, may opt to discontinue receiving stipend funds for the duration of their enrollment in the UWGB Social Work Program, or;

- are in their BSW Program and apply and are accepted to the University of Wisconsin Green Bay Social Work Graduate Program and are awarded the Title IVE Child Welfare Stipend at the advanced level, or;

• after 12 months of documented work search are unable to secure qualified employment within the NE Wisconsin region, or;

• are unable to complete their post-graduation employment commitment due to military deployment, a health or family-related emergency, or other extenuating circumstance.

may request a deferral (extension of time to complete) or exemption (cancellation) of the work obligation by submitting this form to the Child Welfare Coordinator. Upon receipt of supporting documentation, the Child Welfare Coordinator may defer or exempt the stipend recipient from their employment obligation.

Inability to secure qualified employment:

• Attach supporting documentation demonstrating one year (four quarters) of search for qualified employment. (Additional documentation may be requested.)

Extenuating circumstances:

• Attach a brief statement explaining why extenuating circumstances prevent you from completing your post-graduation employment obligation and, if applicable, your plan for completing it.

Please provide your updated contact information:

Name

Mailing Street Address

Apartment Number

City

State

Postal code

Personal Email Address

Telephone Number

Please indicate your reason for deferral or exemption:

I am requesting a deferral.
I am requesting an exemption.

The reason for this deferral/exemption is:

I have been accepted to the University of Wisconsin Green Bay Social Work Graduate Program and have been awarded the Title IV-E Child Welfare Stipend.
I documented 12 months of work search and did not gain employment.
I was deployed by the military.
I have a health or family-related emergency.
I have an extenuating circumstance.

Please provide a description of why you are requesting a deferral or exemption at this time.