Full Name: * UVA Email Address: * Phone Number: * Are you representing an organization or group? * Yes No What organization or group are you representing? How would you categorize your group or organization? Contracted Independent Organization (CIO) Organization sponsored by the Fraternal Organization Agreement (FOA) Special Status Organization Residence Life Group Academic course with a service-learning component Other: How would you categorize Other What is the mission statement of your organization? (1-2 sentences) Provide examples of community service or engagement initiatives (only within the past 2 years) that your organization has undertaken. Feel free to provide links to websites or news articles if relevant. Are you co-sponsoring this project with another organization? * Yes No With what organization(s) are you co-sponsoring this project? Project Proposed date for project: * Proposed title for project, event, or initiative: * What is the total amount of money you are seeking for this project? * $ Please provide a brief description (including timeline) of the project for which you are seeking funds. * How will your project further the goals of public service, ethical community engagement, and civic virtue? * Do you have a plan to evaluate/assess this project after its completion? * Yes No What are the specific metrics that you will use to evaluate its long-term impact? Please describe other sources of funding that you are pursuing and how you will fund your project if you receive a partial award. If you are not able to get full funding from this or other sources, or if you encounter other obstacles, what, if any, backup plans do you have? * Please describe any community partnerships affiliated with your project, including the name, title, and contact information (phone number and email address) for a representative from that community organization. How does this project align with the mission of your community partner(s)? * (Note: A community partner is a non-UVA partner, such as a nonprofit organization. Another CIO, a Greek organization, or a similar UVA-affiliated entity does not qualify). What are the possible benefits, outcomes, and risks for the participants, the sponsor, and the community partner for this project? * Good planning is critical to mutually beneficial partnerships with community members. Please affirm your commitment to cooperative, reciprocal relationships with the Charlottesville community by communicating with your community partner(s). I (or another representative from my organization) have (has) contacted our community partner(s) and informed them of the details and possible risks of this activity. They have signed off on the possibility of supporting this project if it is funded. * Yes No Please share any additional information you would like the Board to have when considering this project and partnership. How did you hear about the PSPB award? * Email or listserv A student organization A class or faculty member Learning in Action website Student Council Other: Which listserv? Which student organization? Which class or faculty member? How did you hear Other Please attach an itemized and sourced budget (including hyperlinks to items for purchase when available). * Files must be less than 2 MB.Allowed file types: pdf doc docx xls xlsx. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
