Application for a University Community Partnership 20-21

Dear Prospective Community Partner,

Thank you for your interest in a partnership with the CSUSM Office of Internships & Service Learning. This form should be completed by a knowledgeable representative at the site who is intricately familiar with the organization's safety policies, procedures, and the potential learning activities that CSUSM students will be engaged in as part of their learning experience.

Note: This form is NOT to be completed by faculty or students.

Organization Information

Legal Business/Organization Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Website *

Contact Information

Full Name of Contact Signing Agreement *

Title of Contact Signing Agreement *

Email of Contact Signing Agreement *

Phone of Contact Signing Agreement *

Phone of Contact Signing Agreement, part 1

Phone of Contact Signing Agreement, part 2

Phone of Contact Signing Agreement, part 3

ext.

Phone of Contact Signing Agreement, part 4

Main Contact information will be uploaded to the databse for students and faculty to view.

Main Contact First Name *

Main Contact Last Name *

Main Contact Job Title *

Main Contact Phone *

Main Contact Phone, part 1

Main Contact Phone, part 2

Main Contact Phone, part 3

ext.

Main Contact Phone, part 4

Main Contact Email *

Are any of the owners or managers employed at CSU San Marcos? *

Yes

Name(s) of Business Owners

Position Description

The following information will be displayed in internship and service learning database for faculty and students to view.

Programs* *

* Only organizations with a non-profit status may apply for the service learning program.

Organization Description & Mission Statement *

Industry Type *

Position Title *

Position Description (e.g. tasks, projects, assignments) *

Learning Objectives and Outcomes *

Desired Qualifications *

Number of positions available *

Length of position (Note: A semester is 16 weeks long.) *

Hours per week *

Is this a paid opportunity? *

Yes

Hourly Rate *

Application Instructions (e.g., supplemental questions, interview, and/or resume) *

Opportunity Dates

Is this a remote opportunity? *

Yes

Is this an on-going opportunity? *

Select "yes" to have your opportunity posted as an on-going basis.

Position Start Date *

Month

Day

Year

Post Expires *

Month

Day

Year

Note: If you are offering an unpaid internship, please review the Department of Labor's guidelines on Internship Programs and the Fair Labor Standards Act to ensure that your internship opportunity meets the stated criteria for an allowable unpaid internship.

Site Safety

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

Yes

Please Clarify *

Will students be working with "behaviorally challenged" populations or working unsupervised with minors? *

Yes

Please Clarify *

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

Yes

Please Clarify *

Would the location be described as a high-crime area, or are there concerns about the parking and work areas being secure or adequately illuminated? *

Yes

Please Clarify *

Have there been any incidents of criminal activity at the organization within the last year? *

Yes

Please Clarify *

Are there concerns with the site's physical location; such as physical, environmental, or inherent hazards that are not addressed adequately by training and security measures? *

Yes

Please Clarify *

Does the internship require working with any hazardous materials, heavy equipment, or heavy machinery? *

Yes

Please Clarify *

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

Yes

Please Clarify *

Is there anything else not covered that might impact the safety and well-being of the students?

Acknowledgement

Site Orientation Requirement *

I understand my organization is required to provide the intern with a safety training/orientation pertaining to potential risks associated with the nature of the industry and organization prior to the start of the internship or service learning hours.

COVID-19 Public Health Guidelines *

I agree that this organization is in compliance with all current COVID-19 Federal, State, and County public health guidelines

As a representative of this company, I acknowledge and agree to the information provided in the CSUSM Community Partner Internship or Service Learning Handbook. *

Clear signature

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