Service Learning Community Partner Request Form Service Learning Community Partner Request Interested in becoming a community partner to work with MIAD Service Learning students? Please fill out this form! "*" indicates required fields Organization InformationName* Organization name Mission Statement*Please provide your organization's mission statement. WebsitePlease provide a link to your organization's website. Address*Please provide your organization's address. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Address/esIf your organization has more than one location, please provide any associated addresses. Phone*Please provide your organization's general phone number.Is this organization a registered nonprofit?* Yes – tax exempt Yes – not tax exempt No – unincorporated community organization No – not-for-profit organization No – for-profit organization What does your organization focus on?*Please choose all that apply. Child care Youth education Adult education Elder care Medical/special needs Community resources Community arts programs Housing/shelter Food pantry/meal program Mental health/wellbeing Physical health/wellbeing Environmental education Land stewardship Animal care Other What other categories apply to your organization? Which semesters will volunteer opportunities likely be available?*Please note that students must begin their volunteer work near the beginning of the semester. Please choose all that apply. Fall (late August through mid December) Spring (early January through late April) Summer (early May through mid July) Select AllDo you require background checks for new volunteers?* Yes No Only for some volunteer opportunities (i.e., working with children) Are there any other special requirements for volunteers?Please describe additional requirements for volunteers, i.e. TB testing, vaccines, etc.Please provide examples of volunteer opportunities that may be available.*Primary ContactPlease provide information for the primary contact (i.e., volunteer coordinator, etc.)Name* First Last Title/Position Job title Email Address* Phone*Do you have any questions you would like to discuss with the Service Learning team?NameThis field is for validation purposes and should be left unchanged. Δ
