The Weissman Center for Leadership and the Liberal Arts and the CBL Program look forward to working with you and your students.

Please complete and submit the form below. If you have any questions, please contact the CBL office in 122 Porter Hall at x3428 or email CBL.

All fields must be completed.

Instructor Name

Department

Email Address

Phone Extension

Course Number

Course Title

Course Description

Estimated Enrollment

Indicate if this CBL course is:

	Speaking Intensive
	Writing Intensive
	Speaking & Writing Intensive

Please describe the community-based learning component(s) of your course

Please note the organizations and the community partners with whom you hope to work during the semester.

How do you hope to work with a CBL Mentor?

If you would like to request a specific student to work as your CBL mentor, please provide her name, information about how you have worked with her in class and/or through the CBL Program, and why she would be a good match for you and your class.

Please describe how you have worked previously with a CBL Mentor or the CBL Program.

Please describe any previous partnerships with a community organization with whom you have worked in the context of previous courses taught.

Please list any questions you may have about the CBL Mentor program.