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This document is for use by an authorized BSWH-affiliated school official/personnel to attest their compliance with the affiliation agreement allowing students and/or faculty to participate in clinical rotations at BSWH. This form is to attest that all faculty and students listed within have met the requirements marked below for participation in the referenced education program. For questions, please email BSWHeduattestations@BSWHealth.org.
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Select all that apply.
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Select all that apply.

List all students and faculty below that have met the above checked compliance requirements. Please complete an additional attestation if more than 50 students.

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By entering your name in the blank you are attesting the above information is correct and true and you are authorized to certify the information on behalf of the school.
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Title of person authorized to attest.
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