Service Learning Request to Initiate Partnership

Please provide the following information to facilitate the posting of your organization's Academic Credit Service Learning opportunity.

This form should be completed by a knowledgeable representative at the Service Learning Site who is intricately familiar with the organization's safety policies and procedures and the potential learning activities that CSUSM students will be engaged in as part of their experience.
(This form is NOT to be completed by faculty or students.)

Requester Name *

Requester Email *

Faculty Partner *

Organization Name *

Street Address *

City *

State *

Zip Code *

Main Contact First Name *

Main Contact Last Name *

Main Contact Job Title *

Main Contact Email *

Do you want to show Main Contact information to students? *

No

Yes

Name of Contact Signing Agreement *

Title of Contact Signing Agreement *

Email of contact signing agreement *

Are any of the student supervisors of your organization also employed at CSUSM? *

No

Yes

Website *

Social Media Site

General Email

Brief description of your organization *

Additional issues addressed/key words for this program

Brief description of the student's activities/responsibilities at this organization *

Instructions to become a volunteer (e.g., supplemental questions, interview, resume) *

Does your site require any of the following? *

Please specify requirement. *

Minimum number of hours you require of a student per semester *

Please provide days and times that students can be on-site and any additional information related to your hours of operation. *

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

Does your site have gender inclusive bathrooms? (i.e.: restrooms that are not designated by gender.) *

No

Yes

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

No

Yes

Please clarify.

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

No

Yes

Please clarify.

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

No

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? *

No

Yes

Please clarify.

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

No

Yes

Please clarify.

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

No

Yes

Please clarify.

Does the student activity require working with any hazardous material, heavy equipment or heavy machinery? *

No

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? *

No

Yes

Please clarify.

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

Will the student receive safety training pertaining to potential risks associated with the nature of the industry, organization, and internship opportunity? *

Yes

No

Comments or questions