Service Learners Application Request Form

Organization Name

Region

Term

Address

Which Chicago neighborhoods and/or suburban communities does your organization serve?

Service Address (if different):

Directions (by public transportation, by car, and parking info)

Phone

Website

Executive Director Name

Executive Director Phone

Executive Director Email

How long has the ED served in this position?

Representative Name

Representative Title

Representative Department/Program

Representative Email

Representative Phone

Preferred mode of contact

Organizational Mission

Major Programs & Services Provided (check all that apply)

Primary Population(s) Served (check all that apply)

1. What mode of service are you looking for from DePaul’s service learning students?

Direct Service

Project-based

Research

Advocacy

2. Would your organization be interested in participating in Community-based Research Projects?

Yes

No

Task #1

Task #1 Description

Task #1 Number of Students

Task #1 Availability needed

Task #2

Task #2 Description

Task #2 Number of Students

Task #2 Availability needed

Task #3

Task #3 Description

Task #3 Number of Students

Task #3 Availability needed

Does your organization require its volunteers to complete a back ground check?

Yes

No

If yes, please specify what type of background check and time needed for approval:

Will you or another representative be available to present a 5-minute organizational presentation at a DePaul campus on one or more days during the first week of the academic quarter?

Fall Quarter

Winter Quarter

Spring Quarter

Summer Quarter

Are you willing to schedule and facilitate a comprehensive orientation for student Service Learners on one or more days during the second week of the academic quarter?

Yes

No

How many hours per 10-week quarter is your organization willing to commit to supervision of service learning students, correspondence and future service planning with a Service Learning Coordinator?

Are you willing to complete a Program Feedback Form at the end of every 10-week quarter providing thoughtful feedback to the Steans Center regarding the level of its support and the performance of all service learning students supervised?

Yes

No

We highly encourage participants to sign up on our DePaul Partners listserv and attend our quarterly Community Development Workshops. Will you be willing to participate?

Yes

No

Name

Date

Title

Current Steans Center Contact

Community Partnerships

Leadership:

Representative Provided for the Steans Center:

Organization:

Service Interest and Opportunities:

Site Representative Commitment: