Student Placement Request for Non-Contracted Sites

California State University East Bay: Off-Camp​​us Academic Activities

Off-Campus academic activities are related to a student's academic program (for credit/for a class) and take place outside of the campus/class setting. 

The CSU requires documentation of student off campus learning activities. Cal State East Bay facilitates this through a record of placement in CalStateS4.

Students seeking to use an opportunity not listed on the CalStateS4 Database must complete this Student Placement Request for Non-Contracted Sites. This includes opportunities where students are paid and unpaid.

The Center for Community Engagement will contact the site to initiate the process, and inform the student when they can complete the record of placement in CalStateS4. Please contact calstates4@csueastbay.edu with any questions. 

STUDENTS SHOULD ONLY SUBMIT THIS FORM AFTER CONFIRMING THE OPPORTUNITY WITH THE AGENCY OR ORGANIZATION.

Please note that when you submit this form, your name is shared with the organization contact you identify below. We also notify your faculty for this course of the submission.

Please select all that apply. Start typing common words to search the list for related activities.

Employer Confidentiality

It is the student's responsibility to ensure they are following any confidentiality requirements of their employer.

This is your supervisor at your place of employment being used for the off campus academic activity.
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Please confirm that the learning experience is part of your current job activities.
This is the person at the organization that you contacted and who agreed to host you for the service opportunity.
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Please provide complete contact information (name, phone, relationship) for your emergency contact person:
The Student agrees to act in a responsible manner while representing California State University and abide by all rules and regulations that govern the site in which he/she has been placed. For more information on student conduct requirements go to http://www20.csueastbay.edu/students/campus-life/student-life/sdja/student-conduct.html.
I understand and acknowledge that there are potential risks associated with this learning activity, some of which may arise from (a) my assigned tasks and responsibilities, (b) the location of the learning activity, (c) the physical characteristics of the Learning Site, (d) the amount and type of criminal activity or hazardous materials at or near the location of the learning activity, (e) any travel associated with the learning activity, (f) the time of day when I will be present at the Learning Site, (g) the criminal, mental and social backgrounds of the individuals I will be working with or serving, (h) the amount of supervision I will receive. I further understand and acknowledge that my safety and well-being are primarily dependent upon my acting responsibly to protect myself from personal injury, bodily injury, or property damage.
Please be aware that medical coverage and services provided by the Student Health Services of CSU East Bay are limited. Medical services not available from the CSU East Bay Student health Services would need to be provided by a separate medical plan such as a family health plan. Students should plan to use their personal medical insurance as a primary medical coverage payment if an accident or injury occurs.
I have read this informed consent, waiver and release and understand the terms used in it and their legal significance. This informed consent, waiver and release is freely and voluntarily given with the understanding that the right to legal recourse against the State is knowingly given up in return for allowing my participation in the activity. My signature on this document is intended to bind and not only myself but also my successors, heirs, representatives, administrators, and assignees. I am 18 years or older. I understand that by providing an electronic signature, I have read, understood and am accepting this waiver.


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