SYC – Pennsylvania Criminal Background Check – Foundations Community Partnership

Meeting Space Reservation

Room Choice(Required)

Type of Meeting(Required)

Preferred Date(Required)

Backup Date(Required)

Reservation Start/End Time(Required)

Please include setup and take-down time in your reservation.

Number of Attendees(Required)

Purpose(Required)

Please describe the gathering.

Organization(Required)

Employer Identification Number (EIN)(Required)

Contact Person(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mobile Phone(Required)

Email(Required)

Proof of 501(c)(3) status(Required)

Max. file size: 2 GB.

Please upload a scan of your organization's 501(c)(3) status document.

Additional comments about your reservation and/or equipment needs

Representative Signature(Required)

Date(Required)

SYC Emergency Contact Form

Host Agency Application

Agency

Agency Website

Agency Address

Contact Name

Email Address

Phone #

Agency Description/Mission

Service-Learning Opportunities & Potential Intern Assignments

Please describe the activities/duties you would anticipate for an intern. Include one to three measurable outcome goals for the internship.

Days/Hours of Agency Operations

What days/hours would the intern work most weeks?

Additional Information and/or Special Conditions or Requirements of Intern, such as regular travel between agency locations.

Intern Supervisor

Please provide name/information for one primary supervisor who will be responsible for managing the intern and communicating with FCP.

Intern Supervisor's Resume or Qualifications

Max. file size: 2 GB.

Please upload a copy of your organization's 501c3 status.

Max. file size: 2 GB.

Please upload your organization's liability insurance certificate, showing coverage for student/interns/volunteers.

Max. file size: 2 GB.

Does the organization, or any of its officers or directors have a personal, financial, or employment relationship with Foundations Community Partnership?

Yes

No

If yes, please describe the nature of this relationship:

Representative Signature

Date

SYC PA Criminal Background Check

Support FCP’s Work in Bucks County

Foundations Community Partnership

Foundations Community Partnership

SYC Emergency Contact Form

Back-up Contact Name(s)

Health Conditions/Allergies