C.A.S.E. Community Partner Application This application is to be completed by community organizations and agencies who wish to partner with the Civic and Service Education (C.A.S.E.) Program here at North Carolina Agricultural and Technical State University. Civic and Service Education (C.A.S.E.) Partner Letter Dear Current and/or Future Community Partner, North Carolina Agricultural and Technical State University is excited about our continued Civic and Service Education (C.A.S.E.) Program, a Service Learning Program which began in the fall of 2006. C.A.S.E. assists undergraduates in selecting Community Partner placement sites. Community Partners are defined as community-based agencies and programs who welcome North Carolina A&T State University s community engaged students and volunteers into their organization. With this in mind, the campus community is encouraged by your support! Many of our students have participated in community and civic engagement experiences in their own communities. The C.A.S.E. Program, however, provides an outlet for students to be involved in valuable and real world experiences through the outreach opportunities provided with your organization. The partnership is beneficial for all stakeholders including the student, community partner, surrounding community, and campus community. If your organization is interested in becoming a Partner return the enclosed application form. If you are already a Partner, please resubmit this form to update our information. Submit the Agency/Organization Information Sheet, Volunteer Information Sheet, Position Description Form and Community Partner Agreement Letter. Include a copy of your organization s mission statement to ensure completion of the application. Once submitted, C.A.S.E. will approve your agency. We here at North Carolina A&T State University along with the Civic and Service Education Program look forward to developing this relationship. Once again, we are sure that this will be an opportunity that will benefit all stakeholders. Therefore, we eagerly await your response and anticipate your mutual eagerness to begin or continue partnering with us. For questions, contact the Office of Student Development at 336.334.7792 or osd@ncat.edu Sincerely, Sharon Hoard, Assistant Director of Leadership and Engagement Office of Student Development Division of Student Affairs Date / Time [Required] Please enter the time of submission. Agency/Organization Information This page will provide information about your agency/organization. Name [Required] Mailing Address [Required] Enter the Agency/Organizations Mailing Address City [Required] Enter the city of Agency/Organization. State of Agency/Organization [Required] Select the state of Agency/Organization. Page 1 of 5 C.A.S.E. Community Partner Application
[ ] Alabama [ ] Alaska [ ] Arizona [ ] Arkansas [ ] California [ ] Colorado [ ] Connecticut [ ] Delaware [ ] District of Columbia [ ] Florida [ ] Georgia [ ] Hawaii [ ] Idaho [ ] Illinois [ ] Indiana [ ] Iowa [ ] Kansas [ ] Kentucky [ ] Louisiana [ ] Maine [ ] Maryland [ ] Massachusetts [ ] Michigan [ ] Minnesota [ ] Mississippi [ ] Missouri [ ] Montana [ ] Nebraska [ ] Nevada [ ] New Hampshire [ ] New Jersey [ ] New York rth Carolina rth Dakota [ ] Ohio [ ] Oklahoma [ ] Oregon [ ] Pennsylvania [ ] Rhode Island [ ] South Carolina [ ] South Dakota [ ] Tennessee [ ] Texas [ ] Utah [ ] Vermont [ ] Virginia [ ] Washington [ ] West Virginia [ ] Wisconsin [ ] Wyoming Zip Code [Required] Enter zip code of Agency/Organization. Phone Number [Required] Enter Phone Number for Agency/Organization. - must be 10-15 digits long and may include only numbers, hyphens, and spaces. Website / URL Please provide your agencies website address. Default: http://www. - http://www.myschool.edu Type of Organization [Required] Indicate what type of agency/organization you are. (Check all that apply) Page 2 of 5 C.A.S.E. Community Partner Application
t for Profit (501C3) [ ] Educational [ ] Political Action.Lobbying [ ] Government [ ] Environment [ ] Religious [ ] For Profit Organization Size [Required] [ ] Single Site [ ] Local/Regional [ ] National Volunteer Information Volunteer Point of Contact [Required] Provide the Name of your Agency/Organization's Volunteer Coordinator or Point of Contact. Email Address [Required] Provide a valid email address for the Volunteer Coordinator or Point of Contact. Ways Volunteers are needed. (Check all that apply) [Required] Please indicate ways you need volunteers at your agency or organization. [ ] Fundraising [ ] Public Relations [ ] Childcare [ ] Horticultural Development [ ] Office Support [ ] Tutoring [ ] Research [ ] Advocacy [ ] Bookkeeping [ ] Sport/Recreation/Outdoors [ ] Maintenance [ ] Legislative Monitoring [ ] Computer support [ ] Grant Writing [ ] Chaperone [ ] Mentoring [ ] Summer Opportunities [ ] Special Events [ ] Other Has your organization worked with NC A&T SU students in the last year? [Required] Is your organization within 5 miles of NC A&T SU? [Required] Is your organization able to reimburse students for travel expense? [Required] Page 3 of 5 C.A.S.E. Community Partner Application
Position Description Form This page if for agencies and organizations to describe the needs of the volunteer positions. Supervisor's Contact Information [Required] Please provide the supervisor's contact information. - must be 10-15 digits long and may include only numbers, hyphens, and spaces. First name: Middle initial: Last name: Email address: Phone number: Address: City: State: ZIP: Supervisor's Email Address [Required] Please provide a valid email address. Target Audience (Check all that apply) [Required] Indicate what type of groups or causes your organization focuses their efforts towards. [ ] Administration [ ] Children [ ] Culture & Ethnicity [ ] Disabilities [ ] Education [ ] Youth [ ] Environmental [ ] Faith Based [ ] Governmental [ ] Health [ ] Political/Advocacy [ ] Technological [ ] Translation [ ] Women Description of Duties [Required] Indicate the duties in which you are seeking volunteers. Skills required for this position. [Required] Indicate any necessary skills volunteers need. Required Attire for position. [Required] Indicate any requirements for volunteers as it relates to attire. Does this position require any of the following? (Check all that apply) [Required] Please indicate which of the following is needed. Page 4 of 5 C.A.S.E. Community Partner Application
[ ] Physical Exam [ ] Vaccinations [ ] Drug Screening [ ] Fingerprinting [ ] Drivers License [ ] Access to own transportation [ ] Criminal background check [ ] Identification (State issued ID, Drives, License, etc.) Will your agency or organization provide any of these requirements or reimburse for their cost? [Required] Does this position require the operation of an automobile? [Required] Will you provide an agency orientation to new service-learning students? [Required] Will there be direct supervision on the job? [Required] Community Partner Agreement Terms and Conditions Checkbox [Required] THIS AGREEMENT IS ENTERED BETWEEN THE SAID AGENCY AND NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY THROUGH THE CIVIC AND SERVICE EDUCATION (C.A.S.E.) PROGRAM. HEREINAFTER THE SAID AGENCY WILL BE KNOWN AS A COMMUNITY PARTNER (CP) FOR THE PURPOSE OF PROVIDING COMMUNITY SERVICE OPPORTUNITIES TO STUDENTS. Students will be made available to the CP through C.A.S.E. for specific community service assignments. C.A.S.E. does not indicate that students assigned are qualified by training for a specific community service assignment. CP agrees that no student will be denied community service opportunities or subjected to different treatment under this agreement on the grounds of race, gender, religion, ethnic background, national origin, ancestry, age, sexual orientation, handicap, marital status, or veteran status. The CP will maintain records reflecting the hours in which each student performs community service provided by the CP. The CP will submit these records to the C.A.S.E. program at the end of each semester as requested. The CP will submit a brief written evaluation (as provided by C.A.S.E) of student volunteers to the C.A.S.E. program each semester as requested. Service-Learning students may not displace workers or duplicate work which causes individuals to become unemployed. Service-Learning students will not organize or bust unions on the CP site, will not work with political organizations or elected officials on partisan efforts, will not engage in any religious activities, will not engage in advocacy work, will not work to benefit for-profit organizations, and will not work for or against unions. The CP will also be responsible for the safety of students while on CP s premises. The CP and/or their staff will not be engaged in illegal behavior or activities. Breach of the aforementioned items will constitute cause for immediate termination of C.A.S.E.-CP relationship. CP will be able to immediately terminate community service students as necessary. CP will contact C.A.S.E. if they terminate a community service student. CP covenants and agrees to fully protect, indemnify and save harmless North Carolina Agricultural and Technical State University, its trustees, officers, and employees, the C.A.S.E. program, student participants in the C.A.S.E. program, and their successors and assigns of and from any and all manner of liability, suits, actions, claims, demands, damages, or expenses arising from or growing out of the community service provided by students under this agreement, including without limiting the generality of the foregoing, losses to property or injury to persons. The CP understands that information included in the C.A.S.E. Community Partner Application may be provided to those interested in developing community-based initiatives. I understand that information included in this agreement is in force on date submitted. Termination of this agreement can be initiated by CP s or C.A.S.E. by giving thirty (30) days notice of termination to the other party in writing. [ ] I Agree Page 5 of 5 C.A.S.E. Community Partner Application