CSSCE Application (Demo) - Messages Improved

Please complete this form to apply for the State Seal of Civic Engagement as a senior or junior at SCUSD.

Student Email *

Student Name *

First

Last

Student ID #: *

Student School *

Grade Level *

12th Grade
11th Grade

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Phone Number

Civic Engagement Project/Activity Summary: *

Please briefly summarize your civic engagement project(s) or activities in one or two sentences:

Meaningful problem(s)/issue(s) you've attempted to address: *

Actions you've taken to understand, build awareness, and/or address the problem(s)/issue(s): *

Which decision-makers or systems of power/governance you've engaged with and how you've engaged with them: *

Key lessons you’ve learned from your civic engagement project/activity: *

Verification of State Seal of Civic Engagement Requirements

Please confirm that you've met the following requirements for the State Seal of Civic Engagement:

1. Passing academic requirements: If you are on track for graduation and have a "C" or better in two or more history/social science courses, please attach your transcript below OR write in your counselor's name and email in "other": *

Please see attached transcript
Providing counselor contact

2. Project Oversight/Witness: Please provide a non-relative adult (mentor, teacher, supervisor, etc.) who has overseen or are impacted by your civic engagement project(s) or activities *

First and Last Name

Overseer Email *

Overseer Telephone Number *

3. Adult Recommender: Please provide a non-relative adult recommender (mentor, teacher, supervisor, etc.) who has reviewed your reflection and would endorse you for the State Seal of Civic Engagement: *

First and Last Name

Adult Recommender Email *

A recommendation form will be emailed to the recommender

Adult Recommender Telephone Number *

4. Peer Recommender: Please provide a non-relative peer recommender who has reviewed your reflection and would endorse you for the State Seal of Civic Engagement: *

First and Last Name

Peer Recommender Email *

A recommendation form will be emailed to the recommender

Peer Recommender Telephone Number *

5. Reflection: Have you responded to all the questions in the student reflection template (tinyurl.com/47a43dp5) and shared your reflection with both of your recommenders? *

YES to BOTH questions
NO

6. Endorsement Forms: Have you directed your two recommenders to fill out the endorsement forms at (https://messagesimproved.com/ssce-endorsement-form/) and verified that they have endorsed you for the State Seal of Civic Engagement? *

Reflection Attachment

Click or drag a file to this area to upload.

If you'd like to attach your reflection (as word, PDF, PPT, video, recording, etc.) as evidence, please attach it here

Terms and Agreement *

I understand and agree to the terms.

In checking the box above, you agree and confirm that all answers and reports are true and accurate. You acknowledge that your administrator may reach out to your provided contacts to confirm your participation.

Please complete this form to apply for the State Seal of Civic Engagement as a senior or junior at SCUSD.

Verification of State Seal of Civic Engagement Requirements

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