Americorps ACCESS Program Application

2013-14AmeriCorps Cross Cultural Education Service Systems(ACCESS) Member Application

AmeriCorps is NOT a job. AmeriCorps is a ONE YEAR COMMITMENT to LEARN,SERVE, and earn a SMALL MONTHLY STIPEND and EDUCATION AWARD! AmeriCorps ACCESS members help immigrant and refugee communitiesgain better access to human services, become economically self-sufficient, and build bridges of understanding with mainstream communities.

If you have other opportunities pending, we ask that you WAIT until you hear back from those opportunities before proceeding with your application process.

Please answerALL questions.

PERSONAL PROFILE Date application completed: ______

1. APPLICANT NAME: ______

Last First Middle

2. Are you a vegetarian or vegan? Vegetarian Vegan Not Applicable

3. CITIZENSHIP:  US citizen Permanent Resident______

Registration NumberExpiration date

4. GENDER:  Female Male

5. DATE OF BIRTH: ______PLACE OF BIRTH: ______ETHNICITY: ______

Month/day/year Country of Origin

6. LIST SPOKEN LANGUAGE(S) AND CHECK FLUENCY LEVEL:

1).______IntermediateAdvanced

2).______IntermediateAdvanced

3).______IntermediateAdvanced

4).______IntermediateAdvanced

The ACCESS program requires all bilingual members with an intermediate fluency level in a second language to take the Professional Interpreter Training. Do you agree to take the Interpreter Training if accepted into the program? Yes No

7. Have you had a name change for any reason? Yes No

If YES, please list name(s) previously used:

1).______2).______

3).______4).______

8. ADDRESS:All information will be sent to this address unless you notify us of any changes.

Mailing: ______

NumberStreetCityStateZip Code

Permanent: (if different from above)______

NumberStreetCityStateZip Code

Home Phone: (_____)______Cell Phone: (_____)______Work Phone: (_____)______

E-Mail: ______

State of Residency (at time of Application): ______

9. Please list all social networks that you are connected with and indicate whether it’s private or public information (i.e. Facebook, MySpace, etc.)

Social networkCheck one: PrivatePublic

______

I have NO social network set-up.

10. List 3 words that best described you.

1. ______2.______3.______

11. Prioritize the following characteristics from MOST important to LEAST important to you: (a) earn money, (b) have a multicultural experience, (c) help others,and (d) explore future job/educational interests.

1. ______2. ______

3. ______4. ______

EDUCATION:Please write highest level of education completed: ______

Are you currently a student?  Yes NoIf yes, what school: ______

If yes: Full-time __ Part-time__

If yes, what class will you be in 2013-14:  Freshman  Sophomore  Junior  Senior  Graduate

Expected Graduation Date: ______

COMMUNITY SERVICE

1. Have you previously served in AmeriCorps? Yes No

If YES, please provide the following program information:

AmeriCorps program name: ______

Term served (i.e. Sept. 1, 1999 – Aug. 31, 2000): ______

Position Type (full-time, part-time, etc.): ______

Did you complete your term of service in this program successfully? Yes No

If NO, please explain why: ______

______

Name of Program Director: ______

Program Director Telephone number: ______

Program Director Email address: ______

Please submit one of the following documents as evidence that you have successfullycompleted your AmeriCorps service term(s): 1) a letter signed by your Program Director or 2) evidence of receipt of education award (print out My.AmeriCorps.gov screen showing that you received your education award or copy of your voucher)

If you cannot, please explain why: ______

______

Does the ACCESS staff have your consent to contact this program to inquire about your performance in this

program? Yes No

AmeriCorps program name: ______

Term served (i.e. Sept. 1, 1999 – Aug. 31, 2000): ______

Position Type (full-time, part-time, etc.): ______

Did you complete your term of service in this program successfully? Yes No

If NO, please explain why: ______

______

Name of Program Director: ______

Program Director Telephone number: ______

Program Director Email address: ______

If you cannot, please explain why: ______

______

Does the ACCESS staff have your consent to contact this program to inquire about your performance in this

program? Yes No

2. Please list all AmeriCorps programs, including VISTA, in which you are applying for the 2013-14 program year:

1. ______2. ______

3. ______4. ______

EMERGENCY CONTACT: Please provide two emergency contacts.

Complete name of local contact person for emergencyPhone including area codeRelationship to you

CERTIFICATION: I certify that all of the statements made in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith. I understand that misinformation or omission of information could result in disqualification and/or termination as an AmeriCorps member. I also understand that my selection for participation in the ACCESS Project will require a National Service Criminal History check (FBI) and a UNCG criminal background check, and sex offender search and I authorize for the aforementioned searches to be completed by the ACCESS Project. I understand that, if accepted, my participation in this program is contingent upon continued funding of the ACCESS Project by the Corporation for National and Community Service.

______

SignatureDate

For Parent or Guardian of Applicants under 18 Years of Age: I have reviewed this application and I authorize my son/daughter/legal ward to apply to AmeriCorps.

______

SignatureDate

Name: ______Relationship: ______Phone: (______)______

Address: ______

Street addressCityStateZip Code

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