Application to Receive Co-Curricular or Community Engagement Credit for Student Activities

Use this form for: PLANNING AN EVENT

  • Student organizations applying for co-curricular OR community engagement credit for an event
  • A student who wants co-curricular credit for shadowing a pharmacist
  • A student who wants co-curricular OR community engagement credit for an activity not listed above
  • COP faculty or staff organizing an event for students


Important reminders:

  • Submit this form at least 2 weeks in advance of the activity.
  • If submitting less than 2 weeks before the activity, we can not guarantee review and approval before the activity date.
  • Student organizations can not advertise activities as having approval for co-curricular credit without receiving approval after submitting this form.


If you have inquiries regarding this form, please reach out to the following contacts:

  • Co-Curricular: jerelle@ufl.edu
  • Community Engagement: swcoffice@cop.ufl.edu

PLEASE NOTE: If you are submitting for a community engagement event: In order for your event/activity to be approved by the SWC Office, the event/activity proposed must be directed toward a target population as defined by the NIH OR the event/service must be located in a medically underserved area as defined by the HRSA Shortage Area Tool.

Select
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Is the service being directed toward a target population as defined by the NIH?*

Community engagement events or activities should focus on one of the following populations that experience health disparities, as indicated by the NIH:


  • People with lower socioeconomic status (SES)
  • Underserved rural communities.
  • People with disabilities.
Is the service being rendered in a medically underserved area as defined by the HRSA Shortage Area Tool?*

The event or activity should be geographically located in a medically underserved area. The HRSA tool can be used to identify such areas. HRSA Shortage Area Tool

What is the address of the underserved area?

Please list the faculty advisor for each of the organizations selected above.

Will COP faculty/staff be present at the event?

Please enter in your @ufl.edu email

For the name, please indicate as Last, First

For example: Patel, Priti (ppatel@cop.ufl.edu)

Brief description of the event/activity (5 sentences MAX)

Occurence*

Is this a re-occuring event?

Number of participants required to implement the activity (if applicable). For example "We need at least 5 people to hold this health fair." If not applicable, please put N/A.

Amount of time each attendee will participate (in hours).

(A maximum of 4 hours can be awarded for each co-curricular activity and a maximum of 2 hours for each community engagement activity.)

Membership*

Is this event/activity available to students who are not members of the organizations listed above?

Which of the following soft skills are practiced by participating in this event/activity? (can select more than one)


Advocacy: Promote the best interests of patients and/or the pharmacy profession within healthcare settings and at the community, state, or national level.


Leadership: Demonstrate the ability to influence and support the achievement of shared goals on a team, regardless of one’s role.


Professionalism: Exhibit attitudes and behaviors that embody a commitment to building and maintaining trust with patients, colleagues, other health care professionals, and society.


Self-Awareness: Examine, reflect on, and address personal and professional attributes (e.g., knowledge, metacognition, skills, abilities, beliefs, biases, motivation, help-seeking strategies, and emotional intelligence that could enhance or limit growth, development, & professional identity formation.

Please describe how participants will practice or learn Leadership during this event.

Please describe how participants will practice or learn Professionalism during this event.

Please describe how participants will practice or learn Self-Awareness during this event.

Type of Activity*

For a shadowing experience, please include the following information:

  1. Pharmacist Name
  2. Degrees
  3. Position Title
  4. Employer
  5. Pharmacist Email

Please use your @ufl.edu email


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