Agency Proposal Form

The Public Service Clinics at the Evans School is intended as a peer and faculty facilitated vehicle to connect the research, organizational change, and capacity building needs of community organizations and public agencies with graduate student degree projects. Each clinic and seminar is limited in size to ten students.

If you have more than one project you wish to submit, please complete a separate form for each project.

If a student is matched with your topic, you will need to meet with this student and clinic professor in December to develop a letter of agreement.

All fields followed by * are required.

Organization: *

Your name: *

Title: *

Street: *

City: *

State: *

Zip Code: *

Phone: *

Fax:

Email: *

Web Address:

Project Contact Individual (if different):

Agency Background Information: *

Please provide some background information about your agency.

Fee Statement

A: If our topic is selected and a successful match is made, my organization agrees to pay a fee of $1250 per student.: *

Yes

Half of the fee is due upon signing a letter of agreement with the student in January and half upon successful completion of the project in June. If no, please complete B.

If yes, please indicate how you would like to pay::

invoice me

credit card

We will contact you for your credit card information.

We request financial assistance in the amount of::

A limited amount of financial assistance is available through the financial assistance fund for agencies unable to pay part or all of the fee.

Please indicate why you are requesting financial assistance.:

Financial Assistance Fund Donation in the amount of:

My organization is eager to support other agencies unable to pay the fee for the Public Service Clinics. Please accept a donation to the financial assistance fund that will go towards helping financially strapped agencies take advantage of the Clinics this year.

List Specific Research Question You'd Like Answered: *

1-2 sentences.

Additional Project Background:

Please describe the project. What would you like to find out or have accomplished, what is the desired project outcome?

What are the key steps that you envision the students will do in this project?: *

What are some possible research resources?: *

Have you submitted a research project to the Public Service Clinics before?: *

Yes

If students are interested in your topic and have more questions, can they contact you directly?: *

Yes

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Agency Proposal Form