Intake Form Initial PICCE Intake Form Please take your time to fill out this information as accurately as possible. It's a long form but it helps us to get a better of who your organization is and what you're about. Once you've completed the form a member of PICCE will reach out to your organization! Organization Name * Organization Phone Number * Organization Address * Organization Address Organization Address Organization Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Organization Email Address * Organization Website/URL Organization Fax Number Contact Name * What is the name of the primary point of contact for INSLP? Contact Title * What is the job title of the primary point of contact? Contact Phone Number * (123)456-7890 Contact Email Address * Secondary Contact Name (optional) Secondary Contact Title Secondary Contact Phone Number (123)456-7890 Secondary Contact Email Address Describe any requirements or restrictions for student volunteers * e.g. age requirement, background check, application, etc. Briefly describe your mission * Give an overview of the need in your organization that you believe could be met by university students * e.g. service opportunities, projects, research, etc. What are your organization's days and hours of operation? What is your organization's tax classification? * e.g. 501(c)(3) Does the organization have a staff member who is responsible for training and supervising volunteers as a part of their job description? * Yes No Does the organization offer an orientation program for new volunteers and Service-Learning students? * Yes No Does the agency offer a training program for new volunteers and Service-Learning students? * Yes No Does the agency require a training program for new volunteers and Service-Learning students? * Yes No Is there a minimum age requirement for volunteers? * Yes No Do you have a minimum number of hours required by volunteers? * Yes No If yes, what is the minimum age? How many hours do you require? What types of volunteers can you accommodate? * Groups (clubs, sororities/fraternities, Days of Service, Alumni Individual Volunteers Service Learning Students Interns College/University Staff and Faculty OtherOther Has your organization worked with Service Learning students before? Yes No Unsure For group volunteers, what is your maximum capacity? Describe any relevant licensure, accreditation, or inspection you have received that would testify to the safety and quality of your organization Does your organization have liability insurance that covers volunteers? * Yes No Does your agency carry other forms of insurance relevant to volunteers? * Yes No Is there anything else we should know about your agency? Intake Checklist If you are human, leave this field blank.
