Sub-Grantee Application Form
2012-2013 Program Year
Application Deadline: 5:00PM EST Friday March 16, 2012
Please review the attached Application Instructions.
Print or type your responses. Do not skip. Complete and accurate responses are required for successful consideration.
You must include a copy of your current volunteer application with your submission.
You must provide copies of or links to relevant promotional and/or recruitment materials.
You must provide a position description for all proposed CVN AmeriCorps Member positions.
For questions, please contact Kristen L. Wolford at .
There are three ways to submit your application:
- Email to . Make sure you identify your program in the file name.
- Fax to 301-270-0901, Attn: Kristen L. Wolford, CVN AmeriCorps Coordinator
- Mail hardcopy to 6930 Carroll Avenue, Suite 820, Takoma Park, MD20912. Must be received by application deadline.
Late or incomplete applications WILL NOT be considered!
Section 1: Program Information
1. Program Name:
2. Name and title of appointed CVN AmeriCorps Program Director:
2a. Has this person worked with an AmeriCorps program before? If so, in what
capacity?
2b. Has this person worked with CVN/AmeriCorps before? If so, in what
capacity?
3. CVN AmeriCorps Program Director Contact information:
Phone number:
Fax number:
Email:
Mailing Address:
Program Website:
Section 2: Program Overview
4. Please state your program’s mission:
5. Do you plan to place AmeriCorps members outside of your program? ___ Yes ___ No
6. If you answered ‘No’ in the previous question, please skip to question 7. If yes, please describe how placement sites are selected. All placement sites must have a Memorandum of Understanding or signed agreement with your program.
7. AmeriCorps members serving with CVN AmeriCorps may not displace or duplicate the role of any regular volunteer serving at an organization or any paid staff member at an organization. How do you ensure that proposed AmeriCorps member positions are compliant with the AmeriCorps supplementation, non-duplication and non-displacement policy?
8. Please describe the value added by AmeriCorps to your program and any placement sites you oversee. Value added refers to the additional benefit a community receives by having AmeriCorps members participate in local service projects. AmeriCorps projects must be able to show how they are responding to an identified local need and how they are positively impacting the community in a specific service area.
9. Please describe your AmeriCorps Member recruitment strategy.
10. Please describe the selection process and relevant criteria for your AmeriCorps members. Programs must demonstrate that members are placed in a fair and equitable manner. For example, programs may require AmeriCorps members to have a particular skill or background that will help them to address national service initiatives.
11. What differentiates the AmeriCorps member from other volunteers serving with your program? (i.e. other educational or training opportunities, opportunities for civic reflection, additional service opportunities)
Section 3: Program Characteristics
12. Please identify the geographic areas (including city and state) that you expect to serve in 2011-2012. Please include the number of AmeriCorps members expected to serve in each area.
13. Populations Served (please check all that apply):
____ Children (0-9 years)____ Youth (10-23 years)
____ Adults (24-55 years)____ Seniors (56+ years)
____ Homeless____ Immigrants
____ Formerly incarcerated persons____ Rural
____ Urban/inner city____ Persons with disabilities
____ At risk children/youth____ Native American communities
____ Ethnically and racially diverse communities____ Uninsured or economically
disadvantaged persons
____ Veterans____ Military Families
Please provide any other relevant description of population served.
14. Program Focus Area (Please check all that apply). These areas are determined by CVN AmeriCorps Performance Measures.
____ Education____ Economic Opportunity____ Healthy Futures
15. Please indicate how many positions you plan to fill under each focus area.
____ Education____ Economic Opportunity____ Healthy Futures
16. Please attach a CVN AmeriCorps position description for each proposed member placement.
17. CVN AmeriCorps will require in-depth reporting for certain Performance Measures. These tactics will include regular service accomplishment reporting, distributing and collecting client surveys for health care related positions and tracking student academic achievement for some teaching positions. Can you certify that your program, placement sites and members are able to provide Performance Measure information at this level?
18. How do you ensure that Performance Measure/Service Accomplishment data provided to CVN AmeriCorps is accurate?
19. What problem(s) will AmeriCorps members address in the communities served? Describe the problem(s) your members will address and specify how many people are affected by the problem(s) in the communities you serve. Provide information about the source and date of the information you’ve used to determine these needs. If you work with placement sites, describe how the sites identify need in the communities they serve.
20. Describe member orientation, training and development activities you plan to implement in 2012-2013.
21. What is your program’s relationship with the community organizations that are likely to be placement sites for your AmeriCorps members? How will you manage that relationship? How will you maintain the quality of service and a positive AmeriCorps member experience at that site?
22. Describe your plan for supervising members, and how it ensures that members will receive adequate support and guidance throughout their terms.
23. What are the minimum requirements in place for placement site supervisor selection?
24. Other than the AmeriCorps education award, what other benefits (housing, health care, transportation, living allowance, etc.) do full-time, part-time, and minimum-time members receive in your program? Try to provide a dollar estimate of these benefits. Please keep in mind that AmeriCorps members have a maximum living allowance stipulation.
25. Describe how you will promote your partnership with CVN AmeriCorps within your program, (including among members and placement sites), and outside of your program.
26. Describe how you will instill and nourish an AmeriCorps identity in CVN AmeriCorps members. How will you make your members and placement sites aware of the AmeriCorps member role? How do you ensure that members are informed about AmeriCorps regulations, resources and opportunities?
Section 4: Organizational Capacity
27. How many staff members are responsible for supporting and managing the AmeriCorps program? Indicate each person’s responsibilities, if they are full or part time and the estimated amount of staff time dedicated to AmeriCorps.
28. Briefly describe how you will evaluate the effectiveness of your program. Who will participate in this evaluation? How will the results be used?
29. Identify all the stakeholders and partners in your program, such as sponsoring organizations, placement sites, churches/congregations, local nonprofits, local government, etc. How do they contribute to your program?
Section 5: Program Requirements
30. Is your program a current Catholic Volunteer Network Member? ____ Yes ____ No
31. Does your program comply with the CVN AmeriCorps Non-Discrimination and Non-Harassment Policy? ____ Yes ____ No
32. Does your program comply with the CVN AmeriCorps Reasonable Accommodation Policy?____ Yes ____ No
33. Does your program comply with the CVN AmeriCorps Drug-Free and Alcohol Free Workplace Policy? _____ Yes ____ No
34. Does your program have adequate liability insurance for all AmeriCorps members?
____ Yes ____ No
35. Does your program comply with restrictions on AmeriCorps activities (Prohibited Activities)? ____ Yes ____ No
36. Please note: AmeriCorps members are not employees and must not displace, replace, supplant, or duplicate current staff responsibilities.
37. Is your criminal history check procedure compliant with the current CVN AmeriCorps criminal history check policy? ____ Yes ____ No
38. Training events for the 2012-2013 term will include required attendance at the 2012 CVN AmeriCorps Annual Training Meeting (in conjunction with the CVN Conference), required orientations and re-orientations for Program Directors, Site Supervisors and Members, as well as participation in ongoing conference calls. How will your program ensure that it is in compliance with these requirements?
Please note: programs that are not compliant with the policies listed above will not be considered for funding.
Section 6: AmeriCorps Slot Request
____ Full Time (1700 Hours, up to 12 months)
____ Part Time (900 Hours, up to 12 months)
____ Minimum Time (300 Hours, up to 12 months)
Section 7: Certification
Application form completed by:
Name: ______
Title:______
Date:______
Approval of applications and any subsequent awards for placement of AmeriCorps members is contingent upon approval of the CVN AmeriCorps grant application and full funding as requested from the Corporation for National and Community Service. All slot allocations are subject to change until official Notice of Award is received.
APPLICATIONS ARE DUE TO CVNAmeriCorps by:
5:00 P.M. EST on Friday March 16, 2012
Submit application and supporting materials to CVN AmeriCorps by (choose one):
- Email to : Make sure you identify your program in the file name.
- Fax to 301-270-0901, Attn: Kristen L. Wolford
- Mail hardcopy to 6930 Carroll Avenue, Suite 820, Takoma Park, MD20912. Must be received by application deadline.
For CVN AmeriCorps Staff Only:
Application Received by:______
Date:______
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