Robert and Yvonne Koob Fund for Student Community Engagement Application

Latest guidelines:   Please visit http://www.uni-foundation.org/foundation/KoobFund/Koobfundinfo.htm

to ensure that you have the latest guidelines and application.

STUDENT INSTRUCTIONS: Please work with the host organization to complete the form and questions.

• Submit to Koob Fund, c/o Julianne Gassman, Wellness and Recreation Center 203, Cedar Falls, IA 50614-0241.
• Application deadline for Spring 2008 internships: November 1, 2007
• Application deadline for Summer 2008 and Fall 2008 internships:   April 1, 2008
• Do not submit electronically.   Do not submit handwritten forms.   Answer all questions.
• Applications that do not meet application guidelines will not be considered.

1.   Intern Information

Name:

Mailing Address:

Primary Phone:                                                                      E-mail:    

Student number:                                                                    Classification:

Major:                                                                                     Minor/Certificate:

G.P.A.(cumulative):                                                               Academic Advisor:

• Please attach a transcript or current copy of your degree audit
• Please provide a list of professional and volunteer experiences.   Please indicate which experiences were volunteer and which were paid.

2.   Organization information

Organization Name:

Supervisor name and title:

Mailing Address:

Phone:                                                                                     E-mail:

What is the mission of the host organization?

• Is this organization a 501(c)3 charitable nonprofit?   □ Yes    □ No
• Is this organization a local, county, state or federal government agency? □ Yes      □ No
• Does the organization assist candidates who are running for elected office? □ Yes      □ No
• Will the intern?   □ Yes      □ No
• Does the organization engage in religious education or proselytizing?   □ Yes      □ No  
• Will the intern?   □ Yes      □ No

3. Internship Information

• Semester(s) of Internship □ Fall 20___□ Spring 20____□ Summer 20____
• How much financial support will the organization provide?___________
• How much financial support is the student requesting from the Koob Fund? ___________
• How many academic credits will the student receive for internship? ___________
• What is the course number for the credit? ___________
• How many hours a week will the intern provide service to the organization? ________For how many weeks?____
• Have you been funded by the Koob Fund previously? ___________   When? ___________

By signing this agreement, you agree that the information contained in this document is true to the best of your ability. Signing this affirms that the committee may contact you, your academic advisor, or your intern site for more information.

_____________________              ________________________                _______________________

Student’s signature:   Date                Acad. Advisor’s signature: Date                Intern Supervisor’s signature:  Date

Application Questions:     3 page limit.   Longer applications will not be considered.   * If you are applying for a subsequent semester of funding, please include accomplishments of your previous term(s).

Overview: (To be completed by the organization and student jointly)

1. Describe the primary responsibilities for the student/intern.
2. Describe a significant project that the intern will undertake that will benefit the student, organization and community.
3. Student to complete: If you received Koob funds during any prior period, please describe your accomplishments during each of the periods.

Student benefits  

1. Student to complete :   What are student’s professional and civic goals?   How will this internship, particularly the intern’s project, help the student to meet these goals and broaden his/her experience?  
2. Organization to complete :   What skills, knowledge, and connections will the student gain, particularly through the intern’s project?
3. Organization to complete:   How will the organization ensure that the student has a positive learning experience?

Organizational benefits

1. Organization to complete :    How will the organization benefit from the student’s internship, particularly the intern’s project?
2. Student to complete:   What skills, knowledge, and work/volunteer experience does the student have that will positively contribute to the work of the organization?

Community benefits

1. Organization to complete:   What are the organization’s strengths that help to create positive community change?
2. Organization to complete:   What outcomes (for the community) will result from student/organization’s efforts, particularly the intern’s project?   Please be as specific as possible .