Student Placement Site Request (new)

STUDENTS SHOULD ONLY SUBMIT THIS FORM AFTER MEETING WITH AND CONFIRMING PLACEMENT WITH THE AGENCY OR ORGANIZATION.

Experiential Learning in the CSU:

In the CSU, academic experiential learning includes off-campus activities that are related to the academic program of the university and generally take place outside of the campus setting. At Cal State East Bay, this may include a variety of courses such as capstone, community engagement, fieldwork, internship, practicum, and service learning. Depending upon the academic department and type of experiential learning, students will need to submit and complete specific information to follow University and CSU requirements.

The Center for Community Engagement (CCE) is here to support students, faculty, and external organizations throughout this process! Please contact calstateS4@csueastbay.edu with any questions.

Students engaged in academic experiential learning (course related/academic credit) at locations not listed on this site must complete this form (Student Placement Site Request) to initiate the review process. It is a legal requirement of the CSU that all organizations and placement opportunities be vetted and approved prior to student placements.

Once a student submits this site request, the organization will need to submit a Request to Initiate Partnership Form. Once that is reviewed and approved by the CCE, a legal agreement may need to be signed by the organization as well. Depending upon how quickly the organization responds to the CCE's request for information and signature, this process may take 10-14 business days.

Students are not allowed to begin site activities until they have received notice of site approval and completion of site documentation from the CCE.

To complete this form you must be at least 18 years of age. If you are not 18 years old, do not submit this form. Please email calstates4@csueastbay.edu for further assistance.

Student Identification Information

Student First Name *

Student Last Name *

NetID *

Student Email Address *

Course Department *

Course Title *

Course Number *

Instructor Name *

Instructor Email Address *

Name of Organization *

Name of Supervisor/Your Contact at Organization *

This is the organization representative who has approved your experiential learning opportunity.

Email of Supervisor/Your Contact at Organization *

Please be sure this information is accurate. Notification of submission will be sent to the contact you have identified.

Expected start date *

Expected end date *

Expected number of hours *

Are you being paid for this experience or the hours you will work with the organization? *

Yes, hourly rate or salary

Yes, one time stipend or other form of compensation such as a scholarship, voucher, etc.

Not being compensated

Students Please Note: If you are a current employee of the organization, meaning you currently work there outside of this experiential learning activity, the process for site review and documentation is the same.

Your work supervisor will need to submit the information requested by the Center for Community Engagement. If your employer does not submit this information, you will not be able to use your place of employment for your experiential learning course.

The Center for Community Engagement is not responsible when students or the organization fail to follow established procedures or submit required information.

Student Activity Agreement - You must be at least 18 years old. *

To complete this form you must be at least 18 years of age. If you are not 18 years old, do not complete this form. Please email calstates4@csueastbay.edu for further assistance.

I am at least 18 years old.

Student Activity Agreement - Acknowledgement of Information Required *

By clicking the statement below, you agree to abide by the terms.

Students are not allowed to begin activities at the site or with the organization until the Center for Community Engagement has received the required information and documentation from the organization, approved the organization, and posted the organization in the CalStateS4 database for placement.

Student Activity Agreement - Medical Coverage *

By clicking the statement below, you agree to abide by the terms.

Medical coverage and services provided by the Student Health Services of Cal State 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 occursM

Student Activity Agreement - No Assumption of Responsibility *

By clicking the statement below, you agree to abide by the terms.

The CSU, California State University East Bay, and the Center for Community Engagement assume no responsibility when students or sites fail to follow established procedures or submit required information.

Student Activity Agreement - Release of Liability *

By clicking the statement below, you agree to abide by the terms.

I understand the legal consequences of signing this document, including (a) releasing the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participation in this Activity, including travel to, from and during the Activity.