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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, section 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 and have a tentative project plan.

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* 8. Describe the civic engagement opportunity. We recognize that community projects 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 12.5 minimum hour component through projects for the community partner and course activities related to civic engagement.

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* 9. Please describe your reflection assignments (e.g. journals, fieldnotes, structured conversations, etc.)

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* 10. Please upload the specific reflection assignments now or submit them by the start of the semester.

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* 11. Please upload your syllabus here, even if it is a draft copy. Make sure that your syllabus includes the civic engagement statement and clearly explains how civic engagement is part of the course. Please provide an updated syllabus by the start of the semester.

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

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* 14. In what ways will students be oriented to the community partner’s mission and the partner’s role in the community? How will students be guided to recognize the significance of their contributions and the impact on the broader community?

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

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

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