Americorps ACCESS Program Application

2014-15 AmeriCorps 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 communities gain 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 answer ALL questions.

PERSONAL PROFILE Date application completed: ______

1. APPLICANT LEGAL NAME: ______Last First Middle 2. Dietary Restrictions - Please check one:  Vegetarian  Vegan  Regular

3. CITIZENSHIP:  US citizen  Permanent Resident______Registration Number Expiration date 4. GENDER:  Female  Male

5. DATE OF BIRTH: ______BIRTHPLACE: ______ETHNICITY: ______Month/day/year

6. LIST SPOKEN LANGUAGE(S) AT ADVANCED LEVEL: 1).______2).______3).______4).______

The ACCESS program requires bilingual members with advanced fluency level in a second language to take the Professional Interpreter Training. 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: ______Number Street City State Zip Code Permanent: (if different from above)______Number Street City State Zip Code

of 4 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, Twitter, etc.) Social network Check one: Private Public ______  ______  ______ 

 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  No If yes, please answer the following:  Name of School: ______ Full-time _____ Part-time______ Year (in fall 2014):  Freshman  Sophomore  Junior  Senior  Graduate  Expected Graduation Date: ______ If UNCG student, what is your UNCG ID number? ______ If UNCG student, are you currently a student employee?  Yes  No o If yes, is the employment part of:  Work Study  Graduate Assistantship o If work study or assistantship:  Department: ______ # of hours per week: ______

COMMUNITY SERVICE 1. Have you previously served in AmeriCorps? Yes No If YES, please provide the following program information: a. 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: ______

of 4 ______Name of Program Director: ______Program Director Telephone number: ______Program Director Email address: ______

Please submit one of the following documents as evidence that you have successfully completed 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

b. 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 successfully completed 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

2. Please list all AmeriCorps programs to which you are applying for the 2014-15 program year: 1. ______2. ______3. ______4. ______3. The ACCESS Project will provide members with member gear including t-shirt, please indicate your shirt size preference: Page 3 of 4 Adult Women Adult Men  X-Small  Small  Medium  Large  X-Small  Small  Medium  Large  X-Large  XX-Large  Other:  X-Large  XX-Large  Other: ______

EMERGENCY CONTACT: Please provide two emergency contacts. 1. Complete name of local contact person for emergency Phone including area code Relationship to you

2. Complete name of local contact person for emergency Phone including area code Relationship 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.

______Signature Date

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.

______Signature Date

Name: ______Relationship: ______Phone: (______)______

Address: ______Street address City State Zip Code