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* 1. Name

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* 2. Email address

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* 3. Department

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* 4. Does this course meet any additional Learning Outcomes (LOs) as part of the Connections Curriculum?

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* 5. I would like to designate...

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* 6. What is the department, number, and title of the course?

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* 7. Community Partner (name, organization, contact information)
By providing this information you are verifying that you have had conversations with this partner.

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* 8. Please upload your syllabus here. Make sure that your syllabus includes the civic engagement statement and clearly explains how civic engagement is part of the course.

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* 9. If your course includes any kind of reflection assignments (e.g. journals, fieldnotes, structured conversations, etc.), please upload those here.

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* 10. Describe the civic engagement opportunity. We recognize that projects and community partnerships may not be fully determined until closer to the start day of the course. Using your best projections at this time, please discuss how you anticipate students will meet the minimum hour component (12.5 hours) through course activities related to civic engagement.

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* 11. How will your course and civic engagement experience help students meet these outcomes?
1. Students will make connections between new knowledge and community experiences
2. Students will understand civic identity and commitment
3. Students will reflect on the value of diversity in communities

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* 12. What opportunities will students have to receive feedback toward the learning outcomes throughout the semester?

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* 13. How will students be introduced to and learn about the mission and work of the community partner? How will they realize the impact of their work on the community partner’s goals?

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* 14. We prefer that you commit to using the Hagen Center's reflection assignment and assessment rubric to evaluate the civic engagement component of the course. Are you willing to do this?

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* 15. Do you have any questions or comments for the Civic Engagement Committee?

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