Southern Illinois University School of Medicine

Southern Illinois University School of Medicine Community Service

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Request for Individually Designed Student Community Service Learning Project Approval

The Community Service Program Guidelines state that community service activities must directly support one or more of the School's objectives for community service. No community service activity will be approved if it impedes or conflicts with the School's educational, patient care, and research responsibilities.

This form must be submitted in sufficient time to ensure that all required approvals may be received at least three weeks before the proposed date of the scheduled event. Please read the Community Service Program Guidelines prior to submitting this form. ALL REQUIRED SIGNATURES MUST BE OBTAINED BEFORE THE EVENT IS SCHEDULED AND PRIOR TO SUBMISSION OF THIS FORM TO TRACEY SMITH OR SUSAN HINGLE.

 

 
Most Fields Are Required
Medical Student
First Name

Last Name
Email
Date of Request
00/00/00
Phone
area code, prefix, number
Project Title
Proposed Date(s) / Time(s) of the Project
Location(s)
Describe the project and how it supports the mission and community service objectives of SIU School of Medicine:
Describe how the need for this activity was identified.
What are you hoping to get out of this experience?
How many hours will you perform?
Thank You!
       
"The mission of the Office of Community Health and Service is to continuously improve the health and health care of people in Central and Southern Illinois, by creating formal and informal, institutional and personal, and innovative and lasting relationships between the SIU School of Medicine and the communities we serve. "

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