If you are working with a particular department, program, or faculty, please list them here
Name of Community Based Organization *
Main Contact First Name
Main Contact Last Name
Main Contact Job Title
Main Contact Email Address
Do you want to show Main Contact information to students?
Are you the main contact for this site?
Your First Name *
Your Last Name
Your Email Address
Street Address
City
State
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
General Email Address
Website
Social media site
Please provide a brief description of your organization's purpose or mission
Which Organization type best describes your site? *
- Select - Administrative Entity Agriculture or Manufacturing Arts, Entertainment or Recreation Charity Organization/Foundation Education - Administration/District Education - Adult School Education - Alternative School Education - College or University Education - Early Childhood Education - Elementary School Education - High School Education - Middle School Education - Multi-level Education - Technical or Vocational Educational Services, Training or Consulting Environmental or Wildlife Organization Financial or Insurance Grassroots Organization Healthcare Facility or Network Historical Society/Museum or Library Hospitality Human, Social, or Employment Services Judicial or Legal Facility/Organization Military Place of Worship/Meeting House Political Organization Public Utilities Real Estate and Development Research Institute Residential or Home Care Facility Retail Trade or Service Sector Science, Technology or Engineering Storage, Trade or Transportation
Please provide information about ongoing opportunities at your site
What kinds of things will students be doing?
Please list any important information about your hours of operation
Include days and times that students can be on-site.
Do you prefer students speak a language other than English?
American Sign Language Arabic Armenian Cambodian Cantonese Chinese Chumash Dutch Farsi Filipino Finnish French Fuchow German Greek Hakka Hawaiian Hebrew Hindi Hmong Hokkien Hungarian Ilocano Irish Italian Japanese Khmer Korean Laotian Mandarin Mixteco Persian Polish Portuguese Punjabi Russian Samoan Scottish Gaelic Serbo-Croatian Somali Spanish Swahili Swedish Tagalog Thai Urdu Vietnamese Welsh Wu Yiddish
2. Logistics Please describe any additional special training the CBO will provide
Site Tour List addresses and descriptions of additional areas CSUMB students will serve:
Risk Identification Will the CBO maintain CSUMB student’s emergency contact info?
Please list any and all health and safety considerations at your site which apply to students serving:
If TB test or background check is required, please indicate if it is paid for by the organization.
Are there specific health and/or safety risks associated with the student’s specific work assignment?
Is there any history of violence, environmental hazards or other health/safety risks on the site?
If yes please explain here
Describe any specific recommendations for precautions for students working at your site:
Submit