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)Adult Education
Affordable Housing
Animal Rights
Arts/Music
Children's Rights
Cultural Awareness
Digital Training
Domestic Violence Prevention and Awareness
English as a Second Language (ESL) Education
Environmental Advocacy and Services
Family
Financial Literacy
HIV/Aids Awareness, Prevention
Homeless Advocacy
Human Rights
Immigrant Rights and Services
Job/Employment Training
LGBTQ Advocacy
Labor Union Advocacy
Neighborhood Associations
Obesity Prevention
Physical/Mental/Developmental
Post-Incarceration Transitioning
Religious Rights, Advocacy
Women's Health/Reproductive Rights/Empowerment
Youth Development and Empowerment
Other

Primary Population(s) Served (check all that apply)Artists
Community Residents
Elderly
Ethnic Community
Ex-Offenders
Homeless
Immigrants
International
LGBTQ
Physically/Mentally Challenged
Youth
Other

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: