SIU School of Medicine Office of Community Health and Service

Southern Illinois University School of Medicine Community Service


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
Date of Request
area code, prefix, number
Project Title
Proposed Date(s) / Time(s) of the Project
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!
"Our mission is to realize the SIU School of Medicine’s commitment to service to the community by cultivating relationships with and among the communities we serve and working with them to improve the health and health care outcomes of people in the region."


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