Chronic Mental Illness – 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: 768 MB.

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

Motor Vehicle Report Permission

Full Name

Date of Birth

Driver's License #

Authorization for Obtaining MVR Information

Yes

As a prospective employee or employee of FCP, I understand that FCP as part of their driver control plan will order my MVR from time to time. I understand that this report will be kept in my personnel file as part of my record. I further understand that I am entitled to a copy of my MVR upon request. Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Foundations Community Partnership or FCP’s insurance broker or commercial auto insurance carrier to obtain my MVR. I agree that a copy of this authorization has the same effect as an original.

Full Name and Date

PA Criminal Background Check

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.

COVID Vaccination

Yes

No

Do you require proof of a COVID vaccination for intern employment? If yes, please note any specifics, if applicable.

COVID Vaccine Requirements, if applicable

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: 768 MB.

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

Max. file size: 768 MB.

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

Max. file size: 768 MB.

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

Category: Chronic Mental Illness

Support FCP’s Work in Bucks County

Foundations Community Partnership

Foundations Community Partnership

SYC Emergency Contact Form

Back-up Contact Names

Health Conditions/Allergies

Motor Vehicle Report Permission

PA Criminal Background Check

Workshop Evaluation

Please Rate this Professional Education Workshop, Items 1 - 8