AmeriCorps Service Application

Phone: (304) 342-7850 Toll Free: 1 (866) 314-KIDS Fax: (304) 3420046 803 Quarrier Street, Suite 500 Charleston, W.Va. 25331 www.educationalliance.org AmeriCorps Service Application Thank you for your interest in becoming an AmeriCorps on the Frontline member! AmeriCorps engages more than 80,000 Americans each year in intensive, results-driven service. Here in West Virginia, nearly 700 members are serving to meet some of the most critical needs in West Virginia, including poverty and illiteracy. AmeriCorps on the Frontline, a program of The Education Alliance, is looking for 20 movers and shakers to serve with atrisk secondary students. These AmeriCorps members will serve in seven West Virginia counties and provide 900 hours of service that changes students lives for the better. AmeriCorps on the Frontline members help at-risk students in Cabell, Calhoun, Doddridge, Monroe, Pleasants, Pocahontas, and Raleigh Counties succeed in school. A year of service as an AmeriCorps member can help you build your resume with valuable experiences whether you are just entering college and starting your career, or looking for a way to give back at any point in your life. Benefits include: $2,775 toward college, graduate school or to pay back qualified student loans. This education award can be transferred to children or grandchildren of members who are 55 years of age or old at the start of service. $6,050 per term living allowance Training opportunities and personal development Do you have what it takes to be an AmeriCorps member? If so, apply today! Please return this application, attached motivation statement, 2 sealed letters of reference and the proof of identity and citizenship form to: Sara Blevins Education Matters Coordinator 820 Madison Avenue Huntington, WV 25704 For more information, please call 304-523-8929 x 106 May 2013 1 P a g e

Position Description Title: Service Location: Reports to: Service Term: AmeriCorps on the Frontline Member Cabell County: Barboursville Middle School, Enslow Middle School, Beverly Hills Middle School, Huntington Middle School and Milton Middle School Sara Blevins, Education Matters Coordinator Service Type: half-time (900 hours) Length: 10 months (approximately 90 hours per month) 12 months (approximately 75 hours per month) Compensation: Education Award: $2,775 Living Allowance: $6,050 per term Eligibility: Must be a U.S. citizen and successfully complete a criminal background check AmeriCorps on the Frontline Members are required to make a 10 or 12 month commitment to the program. A portion of the member s time is spent in training and service projects. Members are required to attend personal and professional development trainings throughout the service year. The following outlines the general performance expectations: AmeriCorps Member Requirements 1. Some college coursework and/or college degree preferred 2. Strong interest in education, early childhood and adolescent development, or social work 3. Experience working with school-age children, families, and education professionals preferred 4. Must be responsible, organized and self-motivated 5. Must maintain positive attitude and display patience in work setting 6. Become an integrated member of your assigned service site AmeriCorps Member Duties 1. Mentor elementary, middle or high school students 2. Supervise small groups of students during the school day to produce school newsletters and other materials for parents and the community 3. Contact students who are absent from school and help students improve school attendance 4. Conduct at least one forum at the middle and high school level to get students ideas about how to improve students attendance, behavior and course performance 5. Maintain confidentiality at all times 6. Work with partner agencies to assist them with program delivery 2 P a g e

7. Maintain appropriate records 8. Complete all member forms and reports (such as time sheets, expense accounts, monthly reports and data sheets) 9. Meet deadlines for all reports and data records 10. Attend and participate in all training sessions (on site, local and statewide) and AmeriCorps service projects 11. Complete a Personal Action Plan and work toward its goals and objectives throughout the year 12. Develop a schedule to have meaningful interactions with your site supervisor at least twice a month 13. Keep Site Supervisor informed of progress and/or problems 14. Work as a member of a team to develop and implement strategies that will help students succeed in school 15. Adhere to the schedules given to you and complete all required assignments of the program 16. Devote your time to accomplishing the AmeriCorps goals. These activities revolve around improving student s attendance, behavior and grade level completion. 17. Adhere to all rules and policies of The Education Alliance s AmeriCorps on the Frontline program and service site. 18. Adhere to the AmeriCorps prohibited activities ( 2520.65) and rules as outlined by the Corporation for National and Community Service. 19. Perform other duties assigned by your Supervisor appropriate to the AmeriCorps program. AmeriCorps members are not employees, they are National Service members who fall into a special category under the Internal Revenue code that is neither employee nor contracted service provider. However, the Internal Revenue Service does consider the living allowance to be income and is taxable. The AmeriCorps living allowance will not affect your eligibility for most needs-based federal programs, including Food Stamps and Section 8 housing. Other benefits that are not affected by the AmeriCorps living allowance include WIC, job training, Pell grants, and VA benefits. However, the living allowance does count as earned income for programs funded under the Social Security Act, including TANF, SSI, and Medicaid. It is important to note that Members will not automatically lose their TANF benefits. That will depend upon the state s eligibility threshold. 3 P a g e

Member Application APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State ZIP Gender Male Female Home Phone E-mail Work Phone How long have you lived in WV? Are you 18 years of age or older? Cell Phone If less than one year, where did you live before? YES NO Date of Birth Social Security # T-shirt Size Polo Size Are you willing and able to participate in a minimum of three 1-2 day long trainings which may require overnight travel? YES NO Are you a US citizen or Permanent Resident Alien? YES NO Have you ever served a full or partial term with another national service program (AmeriCorps, VISTA, Energy Express, NCCC)? YES NO If so, when and with what program? Have you ever been convicted of a felony? YES NO If yes, explain **All AmeriCorps members will undergo a fingerprint background check and a national sex offender check. How did you hear about AmeriCorps on the Frontline? If no, explain how you plan to get to your service site: Do you have access to reliable transportation? YES NO AmeriCorps on the Frontline requires a commitment of 10 months or 12 months. Are you applying for a 10-month or 12-month position? 10-MONTH 12-MONTH Are you available to start on 08/01/12 YES NO AmeriCorps on the Frontline requires members to make a full 10-month or 12-month commitment. Are you willing and able to make this commitment? YES NO NOT SURE If you marked something other than yes, please explain: Emergencies and unplanned situations arise for all of us. Please explain how you plan to handle unexpected situations that may arise while you are at your service site. PERMANENT ADDRESS Please give the name and address of a person through whom you can always be reached 4 P a g e

First Name Last Name Street Apartment/Unit # City State ZIP Relationship Home Phone E-mail Work Phone Cell Phone COMMUNITY ACTIVITIES List and describe your organization memberships and community based service experience. Include social, school, professional and neighborhood projects and programs. Attach additional sheets if necessary. Dates of Participation Name of Group or Organization Describe Activities Performed SKILLS AND EXPERIENCE Please provide examples of your experience in each skill marked. Business Leadership Communications Outreach EXAMPLE: Leadership: Student Council President Community Organization Public Health Computers/Technology Public Speaking Conflict Resolution Construction Counseling Writing/editing Tutoring Youth Development Mentoring Other (specify): In the space below, provide a description of any additional skills and experience that you believe will helpful to you as an AmeriCorps member. Attach additional sheets if necessary. MOTIVATIONAL STATEMENT On a separate sheet of paper, please discuss your interest in community service and the AmeriCorps program. Applications without an attached motivational statement will not be processed. EDUCATION Do you have a high school diploma or GED? YES NO High School From To Did you graduate? YES NO Degree College From To Did you graduate? YES NO Degree 5 P a g e

Other From REFERENCES To Did you graduate? YES NO Degree Please list three references. Please do not use family members, spouses or children as a reference. Full Name Relationship Company Phone ( ) Full Name Relationship Company Phone ( ) Full Name Relationship Company Phone ( ) REFERENCE FORMS Please include 2 reference forms. Ask 2 of your references to fill out the attached reference forms. Each reference must be returned in a sealed envelope signed across the seal by the reference. Applications without 2 reference forms will not be processed. Please do not ask family members, spouses or children to fill out the reference form. PREVIOUS EMPLOYMENT Company Phone ( ) Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO Company Phone ( ) Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO 6 P a g e

Company Phone ( ) Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO MILITARY SERVICE Branch From To Rank at Discharge Type of Discharge If other than honorable, explain REASONABLE ACCOMODATIONS I understand that AmeriCorps on the Frontline and its host sites comply fully with EOE standards and will make every effort to provide reasonable accommodations for disclosed disabilities. I can perform the essential functions of my service description with or without reasonable accommodations. YES NO CERTIFICATION AND SIGNATURE 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. Misinformation or omission of information could result in disqualification or termination as an AmeriCorps member. If I am selected for participation in AmeriCorps on the Frontline, I understand that a background and security check will be conducted. I understand that I may also be required to submit to a physical examination including drug and/or alcohol testing. PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authority for collecting information from you in this application is contained in 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C 4953 of the Domestic Volunteer Service Act of 1973 as amended. You are advised that submission of the information is entirely voluntary, but the requested information is required in order for you to participate in AmeriCorps. The principal purpose for requesting this personal information is to process your application for acceptance into AmeriCorps on the Frontline, and for other general routine purposes associated with your participation in an AmeriCorps program. These routine purposes may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests, to present and former employers, references provided by you in your application, and educational institutions, for the purpose of verifying the information provided by you in your application. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information will not otherwise be disclosed to entities outside of AmeriCorps and the Corporation for National and Community Service without your prior written permission. Printed Name Signature Date 7 P a g e

Proof of Identity & Citizenship Proof of Identity A valid driver s license is adequate verification of identity. Last Name First M.I. Street Apt/Unit # Social Security # License # Expires Date of Birth Place of Birth Sex Race Height Weight Eyes Hair Proof of Citizenship Any one (1) of these listed documents is adequate verification of eligibility. A social security card is not adequate documentation to confirm citizenship or resident alien status. Birth Certificate from one of the 50 states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, or the Northern Mariana Islands Valid U.S. Passport issued to the individual as a U.S. citizen U.S. Department of State Form FS-240, Report of Birth Abroad of a Citizen of the USA U.S. Department of State Form FS-545, Certification of Birth Abroad U.S. Department of State Form DS-1350, Certification of Report of Birth Certificate of U.S. Naturalization (Form N-550 or N-570) Certificate of U.S. Citizenship (Form N-560 or N-561) Permanent Resident Card (Form I-551) Alien Registration Card Receipt (Form I-551) A passport indicating that U.S. Citizenship & Immigration Services (USCIS) has approved it as a temporary evidence of lawful admission for permanent residence An Arrival-Departure Record (Form I-94) indicating that the USCIS has approved it as a temporary evidence of lawful admission for permanent residence Other If one of the above primary documents is not available, the program must obtain written approval from the Corporation for National and Community Service that other documentation is sufficient to demonstrate the individual s status as a U.S. citizen, U.S. national, or lawful permanent resident. Retain approval from CNCS in the member file. Document Identification Number (if applicable): FOR OFFICE USE ONLY Attached is a copy of the applicants: Proof of Identity Proof of Citizenship NSOPR (www.nsopw.gov) Applicant determined as: Eligible, can serve Not Eligible, cannot serve By signing below, I verify the enclosed applicants identity and proof of citizenship comply with the AmeriCorps grant requirements and have attached copies of the documentation to this form. Printed Name, County Representative Signature Date 8 P a g e

Reference Form 1 PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED ACROSS THE SEAL, DIRECTLY TO THE APPLICANT FOR OFFICE USE ONLY Reference was verified on by By signing below, I verify this reference: County Representative, Signature REFERENCE FORM TO THE APPLICANT: Please complete the information below and give this form to each of your references. Please ask work supervisors, clergy, teachers, counselors, coaches or someone else who is familiar with your motivation, community involvement, personal background, employment, education, and professional skills. References from family members, spouses, and children will not be accepted. Applicant s Name City State Zip Code Home Phone Work Phone REMAINDER OF THE FORM IS TO BE COMPLETED BY PERSONAL REFERENCE ONLY The person named above is applying to be an AmeriCorps member. The applicant has indicated that you would be able to evaluate his or her qualifications and provide us with a candid recommendation. The success of AmeriCorps depends largely upon an appropriate match between programs and members. Considerable value is placed on personal references during the application review and selection process. Your input is greatly appreciated. Name of Reference Position/Title Organization/Institution City State Zip Home Phone Work Phone Email How long have you known the applicant? Years: Months: Please describe how you know the applicant. WORK Please comment on such qualities as the applicant s level of dependability, initiative, punctuality, reliability, ability to work with minimal supervision and as a member of a team. In your opinion, how competent is this applicant, as demonstrated by work in the community, in school, on the job, or in a position of responsibility? Please check one. 9 P a g e

OUTSTANDING ABOVE AVERAGE SATISFACTORY BELOW AVERAGE UNSATISFACTORY RELATIONSHIPS WITH OTHERS AmeriCorps members must serve and communicate with people of varied cultural, economic, educational, racial, and religious backgrounds. Please comment briefly on the applicant s relationships with others and ability to work as a member of a team. EMOTIONAL MATURITY Please comment on the applicant s ability to adapt and work under difficult and changing conditions. COMMITMENT The AmeriCorps program to which the applicant is applying requires a 10-month or 12-month commitment. Please comment on the applicant s ability to follow through with things that he or she starts and his or her overall ability to honor commitments. ADDITIONAL COMMENTS AND SUPPORTING INFORMATION If you wish, please attach additional sheets to explain any of your ratings and anything else about this applicant that you feel is relevant to serving in AmeriCorps such as the applicant s desire to serve others, overall maturity, work ethic, flexibility, and dependability. Explain any reservations you may have regarding the applicant s participation in the AmeriCorps program. OVERALL RECOMMENDATION What is your overall recommendation? I recommend the applicant without reservation I have some reservations, but I believe the applicant will succeed in serving with AmeriCorps I do not recommend this applicant for AmeriCorps service CONFIDENTIALITY STATEMENT I AUTHORIZE AmeriCorps on the Frontline to identify me as the source of this reference and to release a copy of this reference in its entirety upon request to the applicant I DO NOT authorize AmeriCorps on the Frontline to identify me as the source of this reference, nor do I authorize the release of a copy of this reference in its entirety upon request to the applicant CONFIDENTIALITY STATEMENT (PLEASE USE BLUE INK) Printed Name Signature Date 10 P a g e

Reference Form 2 PLEASE RETURN THIS FORM, IN AN ENVELOPE SIGNED ACROSS THE SEAL, DIRECTLY TO THE APPLICANT FOR OFFICE USE ONLY Reference was verified on by By signing below, I verify this reference: County Representative, Signature REFERENCE FORM TO THE APPLICANT: Please complete the information below and give this form to each of your references. Please ask work supervisors, clergy, teachers, counselors, coaches or someone else who is familiar with your motivation, community involvement, personal background, employment, education, and professional skills. References from family members, spouses, and children will not be accepted. Applicant s Name City State Zip Code Home Phone Work Phone REMAINDER OF THE FORM IS TO BE COMPLETED BY PERSONAL REFERENCE ONLY The person named above is applying to be an AmeriCorps member. The applicant has indicated that you would be able to evaluate his or her qualifications and provide us with a candid recommendation. The success of AmeriCorps depends largely upon an appropriate match between programs and members. Considerable value is placed on personal references during the application review and selection process. Your input is greatly appreciated. Name of Reference Position/Title Organization/Institution City State Zip Home Phone Work Phone Email How long have you known the applicant? Years: Months: Please describe how you know the applicant. WORK Please comment on such qualities as the applicant s level of dependability, initiative, punctuality, reliability, ability to work with minimal supervision and as a member of a team. In your opinion, how competent is this applicant, as demonstrated by work in the community, in school, on the job, or in a position of responsibility? Please check one. 11 P a g e

Interview Form FOR OFFICE USE ONLY Interview Date NOTE: Comments below should specifically relate to the requirements and qualifications of the open position as outlined in the Position Description I. His/her strengths in relation to this position are: II. His/her weaknesses in relation to this position are: III. Rate the applicant from 1 to 10 (1=poor; 10=excellent): Application 1 2 3 4 5 6 7 8 9 10 Interview 1 2 3 4 5 6 7 8 9 10 IV. Recommended action: Offer Reject Other (Please explain) Signature of Interviewers: Recommendation for Service The following documents have been completed and are attached to this form. Member Application Interview Form Date of Interview: Motivational Statement Proof of Identity & Citizenship Form Reference Form 1 Copies of Proof of Identity & Citizenship Attached Reference Form 2 National Sex Offender Public Registry (NSOPR) www.nsopw.gov Verified References (2) By signing below, I verify the enclosed applicants identity and proof of citizenship comply with the AmeriCorps grant requirements and recommend the applicant for service. Printed Name, County Representative Signature Date The Education Alliance s Approval The following documents have been verified by The Education Alliance. Complete Application Packet 2 nd Interview Date of Interview: Clean NSOPR Check Date: By signing below, I verify the applicant has a clean NSOPR check and approve the applicant for service. Printed Name, The Education Alliance Signature Date 13 P a g e