Name of Business/Organization:

Address:

City:

Zip:

Person Completing Form:

Title:

Phone:

E-Mail:

Is there a preference for a specific school level or population?
Please check as many boxes as apply.

Elementary
Middle
High

Technical Center
Special Student Center

Is employee release time available to the partnership? Yes No

If yes:
1. How many employees are available to participate?
2. Are employees paid for volunteering during workday? Yes No
3. Are there a specific number of hours that employees may donate each week or month? Yes No If yes, state number:
4. What time of day (during school day) are employees available?
5. Is there a blackout on certain days of the week?

Is there a particular area of interest?

Reading
Math
Science Technology
Special Education
Social Studies
Fine Arts

Foreign Language
Language Arts/English
Drop-out Prevention
Economics
Other:

Activities of interest:

Tutors
Mentors
Classroom speakers
Classroom assistance
Field Trip/Shadowing
Internships

Special event sponsorship
Incentives for motivation of students
Staff development
Curriculum enrichment
Serve on School Advisory Forum
Other:

Financial Resource (Cash and In-kind)

Are financial resources available to the partnership? Yes No

If yes, approximately how much?

Do schools need to apply for financial resources through corporate headquarters? Yes No

Are in-kind resources available to the partnership? Yes No

If yes, what and approximately how much? (For example, can you donate food, clothing, computers, school supplies, or books?)

Is an incentive coupon available? Yes No

If so, provide the school with a realistic forecast of the the type and number of coupons available per year.

Has your incentive program been approved by the Superintendent’s Screening Committee? Yes No

Note:  To provide incentive coupons, you must first submit an application through the Superintendent’s Screening Committee to insure that your program meets district guidelines. 

If your proposed partnership consists solely of incentives, you do not need to complete the Business Resource Assessment.  Apply directly through the Superintendent’s Screening Committee.

Superintendent’s Screening Committee: http://www.getinvolvedineducation.com/screening

What activities are of interest to you to receive in return for your partnership?
Thank you letters to employees, preferably from students.
Student art to display at work site.
Articles about partnership in school newsletter and media releases.
Invitation to attend PTA/PTO meetings and other school events.
Other:

The following programs are not part of the Partners In Education Business Resource Assessment process:

• Fundraisers that require parents to spend money at your place of business.
• One-time or short-term scholarships to fee-based activities.
• Distribution of flyers for products or services