Service Learning New Opportunity Form 20-21

Dear Community Partner,

Please submit your new opportunity using this form. Your new opportunity will be reveiwed and if approved, uploaded to the Service Learning Database. Thank you for supporting the service learning students.

Note: This form is ONLY to be completed by current community partners.

Organization Information

Legal Business/Organization Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Website *

Contact Information

Main Contact information will be uploaded to the database 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 *

Opportunity Description

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

Opportunity Title *

Opportunity 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 *

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

Has a student been selected for this service learning opportunity? *

Yes

Student(s) Name: *

Is this a virtual opportunity? *

Yes

Is this an ongoing opportunity? *

Yes

Position Start Date *

Month

Day

Year

Post Expires *

Month

Day

Year

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 service learning require working with any hazardous materials, heavy equipment, or heavy machinery? *

Yes

Please Clarify *

Are there any concerns as to the service learning 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?

Are you interested in offering an internship opportunity? *

Yes

Acknowledgement

Site Orientation Requirement *

I understand my organization is required to provide the service learning student with a safety training/orientation pertaining to potential risks associated with the nature of the industry and organization prior to the start of the 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 Service Learning Handbook. *

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