Request to Initiate Campus-Community 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 service learning, students are able to examine the role of community organizations and contribute to them while also enhancing their understanding of course content.

Organization Name:________________________________________________

Type of Organization:________________________________________________

WEBSITE:_____________________________________________________

General Contact Details of Contact person as Organisation:

Title:  __                                                                   Name and Surname:__________________________

Mobile Number:________________________     Office Number:____________________________

E-mail:__________________________________

Address:

Street Address:_______________________________________________

Suburb:__________________________________   City:_________________________

Province:______________________________                     Code:_____________________

  What is the Mission of the Organization?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ICommunity Issues Addressed by the Organization (check all that apply):

Elementary School

 

For Profit

 

Animal Welfare

 

Middle School

 

Non-Profit

 

Arts & Culture

 

High School

 

Faith Based

 

Community/Economic Development

 

Social Services – Children & Youth

 

Youth – Recreational Programs

 

Women’s Rights

 

Technology

 

Youth – School-Based Programs

 

Arts & Culture

 

Animal Welfare

 

Environmental

 

Other:

 

 

Request to Initiate Campus-Community Partnership

 

What is the minimum number of students can you accommodate at our site in a service project per term?_________________________

 Days and hours you will accept students for service (check all that apply)

 

12:00 – 13:00.

13:00- 14:00

14:00 p.m. – 15:00

15:00 – 16:00

16:00 – 17:00

Monday

 

 

 

 

 

Tuesday

 

 

 

 

 

Wednesday

 

 

 

 

 

Thursday

 

 

 

 

 

Friday

 

 

 

 

 

Saturday

 

 

 

 

 

 

 Service Sites:

 

On- Site Supervisor name:______________________________

 

Phone:___________________________________               E-mail:_________________________

 

  Briefly describe any ongoing needs or special projects with which students can assist agency staff

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Risk Management & Partnership-

Would the Organization be able and willing to complete a self-assessment of risks inherent to the students’ service environment associated with the organization and service sites (facility hazards, location concerns, client or personnel issues, etc.)?

                                                  Yes                                                                                                         No

(2) In the event that additional, unforeseen risks become apparent, the Organization must agree to timely communicate all risk-related concerns to the University. Please indicate the Organization’s acknowledgement of this requirement:

                  Accept                                                                              Decline