<p> 2014-15 AmeriCorps Cross Cultural Education Service Systems (ACCESS) Member Application </p><p>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. </p><p>If you have other opportunities pending, we ask that you WAIT until you hear back from those opportunities before proceeding with your application process. </p><p>Please answer ALL questions.</p><p>PERSONAL PROFILE Date application completed: ______</p><p>1. APPLICANT LEGAL NAME: ______Last First Middle 2. Dietary Restrictions - Please check one:  Vegetarian  Vegan  Regular </p><p>3. CITIZENSHIP:  US citizen  Permanent Resident______Registration Number Expiration date 4. GENDER:  Female  Male</p><p>5. DATE OF BIRTH: ______BIRTHPLACE: ______ETHNICITY: ______Month/day/year </p><p>6. LIST SPOKEN LANGUAGE(S) AT ADVANCED LEVEL: 1).______2).______3).______4).______</p><p>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).______</p><p>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</p><p>Page 1 of 4 Home Phone: (______) ______Cell Phone: (______) ______Work Phone: (______) ______E-Mail: ______State of Residency (at time of Application): ______</p><p>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 ______  ______  ______ </p><p> I have NO social network set-up.</p><p>10. List 3 words that best described you. 1. ______2.______3.______</p><p>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. ______</p><p>EDUCATION: Please write highest level of education completed: ______</p><p>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: ______</p><p>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: ______</p><p>Page 2 of 4 ______Name of Program Director: ______Program Director Telephone number: ______Program Director Email address: ______</p><p>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)</p><p>If you cannot, please explain why: ______</p><p>Does the ACCESS staff have your consent to contact this program to inquire about your performance in this program? Yes No</p><p> 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: ______</p><p>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)</p><p>If you cannot, please explain why: ______</p><p>Does the ACCESS staff have your consent to contact this program to inquire about your performance in this program? Yes No</p><p>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: ______</p><p>EMERGENCY CONTACT: Please provide two emergency contacts. 1. Complete name of local contact person for emergency Phone including area code Relationship to you</p><p>2. Complete name of local contact person for emergency Phone including area code Relationship to you</p><p>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. </p><p>______Signature Date</p><p>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. </p><p>______Signature Date</p><p>Name: ______Relationship: ______Phone: (______)______</p><p>Address: ______Street address City State Zip Code</p><p>Page 4 of 4</p>