Robert and Yvonne Koob Fund for Student Community Engagement 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.
- Spring 2016 internship applications are due Wednesday, December 2, 2015, 5pm to WRC 203.
- Do not submit electronically. Do not submit handwritten forms. Answer all questions.
1. Intern Information
Primary Phone: E-mail:
Student number: Classification:
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
Supervisor name and title:
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 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? ___________
- 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: Only three pages for this section will be permitted.
*If you are applying for a subsequent semester of funding please describe accomplishments of your first term.
Overview: (To be completed by the organization and student jointly)
- Describe the primary responsibilities for the student/intern.
- Describe a significant project that the intern will undertake that will benefit the student, organization and community.
- 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?
- Organization to complete: What skills, knowledge, and connections will the student gain, particularly through the intern’s project?
- Organization to complete: How will the organization ensure that the student has a positive learning experience?
- Organization to complete: How will the organization benefit from the student’s internship, particularly the intern’s project?
- Student to complete: What skills, knowledge, and work/volunteer experience does the student have that will positively contribute to the work of the organization?
- Organization to complete: What are the organization’s strengths that help to create positive community change?
- 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.