20/21 Community Scholars Training Program

2020/2021 Penn Community Scholars Training Program

Registration Form

The Penn Community Scholars Program (CSP) was developed to foster and promote community-academic partnerships and community-based participatory research. This 12-session virtual training is designed to increase community knowledge of the necessary skills and practices to form productive, collaborative academic partnerships to better assess the needs and outcomes of community-based work. Initially a collaboration between the University of Pennsylvania’s Robert Wood Johnson Foundation Clinical Scholars Program and the University of Pennsylvania’s Center for Public Health Initiatives (CPHI), the Penn CSP is now housed in the Penn Injury Science Center with funding from the Office of the Provost.

Ten to twelve community-based organizations will be selected via a competitive application process and may submit 1 individual to attend from their organization. This representative will complete twelve sessions (dates listed below) and make a final pitch presentation. Participants will also receive a stipend for completing all sessions. Sessions will take place via zoom due to the ongoing COVID-19 pandemic.

All sessions will occur Thursday evenings, 5:30 pm - 7:30 pm

Session 1: 10/29

Session 2: 11/05

Session 3: 11/19

Session 4: 12/03
Session 5: 12/17

Session 6: 01/14

Session 7: 01/28

Session 8: 02/11
Session 9: 02/25

Session 10: 03/11

Session 11: 03/18

Session 12: 03/25

Culminating Pitch Symposium: 4/9 (9 am - 12 pm)

Questions may be directed to: Sara Solomon, Deputy Director PISC at sarasol@upenn.edu.

Question 1. About your organization

Organization name:

Organization address:

Organization website:

Contact name:

Contact title:

Phone number:

Email address:

Preferred method of contact?

Question 2. Briefly describe the mission of your organization:

Question 3. Briefly describe the characteristics of your primary target population/clients including the following:

Age range:

Gender:

Race(s):

Ethnicity:

Income:

Geographic location of population served/ client residence:

Other:

Question 4. Does your organization serve clients that live in West or Southwest Philadelphia?

Yes
No (if no, skip to question #6)

Question 5.

About what percentage of clients that you serve reside in West or Southwest Philadelphia:

1-25%
26-50%
51-75%
76-100%

Question 7. Which, if any, community-academic partnerships are you a part of? If none, are there any academic partnerships you are interested in matching with?

Question 8. What do you hope to get out of this experience?

Question 9. Can you commit to attending the twelve training sessions as a representative of your organization?

Yes
No

Question 10. Does the leadership of your organization support your participation?

Yes
No

Question 11. Who from your organization will be participating in the Penn Community Scholars Program

Primary Participant Name

Title

Email address

Thank you for completing the registration form for the 2020-2021 Penn Community Scholars Training Program!

Signature (electronic)

Date