OLD Request to Initiate a Service-Learning Partnership

This form is to be completed by a representative of the community-based organization (CBO) who will be the main point of contact between the organization and CSU Channel Islands. After this form has been submitted, the Center for Community Engagement's Community Partner Coordinator will contact you to discuss insurance requirements and the service learning agreement.

Name of Organization *

Main Contact First Name *

Main Contact Last Name *

Main Contact Position Title *

Main Contact Email Address *

Main Contact Phone *

Main Contact Phone, part 1

Main Contact Phone, part 2

Main Contact Phone, part 3

ext.

Main Contact Phone, part 4

Street Address *

City *

State *

Zip Code *

Website *

What is a general description of your organization? *

Which Organization type best describes your site? *

Please confirm the following CBO requirements for partnership can be met: *

CBO maintains a current non-profit 501c(3) status or is a government agency or school district

CBO maintains general liability insurance.