Campus Partners - Request to Initiate a Campus Partnership

Many organizations find that working with college students allows them to expand the capacity of their organization or agency while allowing them to provide students with an opportunity to have positive learning experiences. Through community learning and volunteering, students are able to examine the role of the community organizations and contribute to them. Community Engagement will do everything possible to locate the right students to meet your needs. Please complete and submit this form.

*If you do not have the necessary information handy to complete this form please exit the online form and reopen a new form when you are ready.

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Name of Your Organization *

Which Organization type best describes your site?

Name of Organization's Director

Please list the name and title of the person who has the authority to sign a partnership contracts from CSUN.

Campus Address

State

Mail Code

Does your organization have additional locations? *

Yes

Name of Site

Street Address

City

State

Zip Code

Name of Site Supervisor

Phone Number

Phone Number, part 1

Phone Number, part 2

Phone Number, part 3

Would you like to list a third location?

Yes

Name of Site *

Street Address

City

State

Zip Code

Name of Site Supervisor

Main Contact: The main contact information provided below will be used by Community Engagement staff members to contact your organization. CSUN students will not have access to this information unless otherwise designated.

Phone Number

Please note: Any further locations may be emailed to communityengagement@csun.edu

Phone Number, part 1

Phone Number, part 2

Phone Number, part 3

Main Contact First Name *

Main Contact Last Name *

Main Contact Job Title *

Main Contact Email Address *

Main Contact Phone *

Main Contact Phone, part 1

Main Contact Phone, part 2

Main Contact Phone, part 3

Is this the contact information you would like students to use? *

Yes

Student Contact First Name

Student Contact Last Name

Student Contact Job Title

Student Contact Email Address

Student Contact Phone Number

General Phone Number *

General Phone Number, part 1

General Phone Number, part 2

General Phone Number, part 3

General Email Address *

Website

Organization Mission Statement

Please list a project description or any needs your organization may have

If you are already connected with a CSUN faculty member for a Service Learning or Internship project, please list who.

We will keep the faculty member up to date on the status of your partnership with CSUN

What programs are you interested in partnering with?

Other Programs, please explain

Are there specific departments with which you would like to be partnered (check all that apply)?

Please list any and all health and safety considerations at your site which apply to students serving:

Please list any important information about your hours of operation

Include days and times that students can be on-site.

What are the minimum number of hours you require of a student serving at your site?

hours

What is the maximum number of students your site can accept?

students

Is bilingual required at this site?

Yes

Risk Management & Partnership Training

1. In the event that additional unforeseen risks become apparent the Organization must agree to communicate all risk-related concerns immediately to the Office of Community Engagement. Please indicate the Organization’s acknowledgement of this requirement. *

I accept

I decline

Self Assessment of Risks

1. Will the students be supervised less than 50% of the time or will the supervisor be responsible for overseeing more than 8 people? *

Yes

1a. If Yes Please Describe

2. Will the students be working with populations that are identified as “behaviorally challenged? *

Yes

2a. If Yes Please Describe

3. Will the students be working with individuals who have a known criminal background or history of violent behavior? *

Yes

3a. If Yes Please Describe

4. Does the placement require working with any hazardous materials, heavy equipment, or heavy machinery? *

Yes

4a. If Yes Please Describe

5. Are there any concerns as to the Learning Site’s Emergency Plan or regarding non-working fire-rated doors or blockages to the exits and hallways? *

Yes

5a. If Yes Please Describe

6. Is there anything else not covered that might impact the safety and wellbeing of the students? *

Yes

6a. If Yes Please Describe

7. Does the placement require working with minors? *

Yes

7a. If Yes Please Describe

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