Request to Initiate Campus-Community Partnership
Many organizations find that working with 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 *
Your answer
Type of Organization *
Your answer
Organisation website
Your answer
General Contact Details of Contact person as Organisation
Title
Name *
Your answer
Surname *
Your answer
Office Number
Your answer
Mobile Number *
Your answer
E-mail *
Your answer
Organisation Adress
Street Address *
Your answer
Suburb *
Your answer
City *
Your answer
Province *
Your answer
What is the Mission of the Organization? *
Your answer
Community Issues Addressed by the Organization (check all that apply):
Profit
Non-Profit
Educational
Elementary School
Middle School
High School
Educational
Art
Drama
Dance
Arts & Culture
Community Gardening
Recycling
Rehabilitation
Conservation
Environment
Social Services – Children & Youth
Youth – Recreational Programs
Youth – School-Based Programs
Youth Development
Community Development
Economic Development
Womens Rights
Other Development
Animal Welfare
Animal Rights
Welfare not pertaining to Human
Training
Technology
What is the minimum number of students can you accommodate at the site in a service project per term?
Your answer
Days and hours you will accept students for service (check all that apply)
*
12:00 – 13:00
13:00- 14:00
14:00  – 15:00
15:00 – 16:00
16:00 – 17:00
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
On- Site Supervisor *
Name
Your answer
*
Surname
Your answer
*
Phone/ Mobile Number
Your answer
*
email
Your answer
Briefly describe any ongoing needs or special projects with which students can assist agency staff: *
Your answer
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.)?
Required
*
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:
Required
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