Attachment 10 - Member Enrollment Form


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Attachment 10 - Member Enrollment Form (pdf)


Text for the 
AmeriCorps Enrollment Form

AmeriCorps Illinois

AMERICORPS ENROLLMENT FORM
National & Community Service Logo

Completion of this form is required to enroll an AmeriCorps member in the National Service Trust, making the member eligible for an education award upon successful completion of his or her term of service. It also provides the Corporation for National and Community Service with basic demographic data.

DIRECTIONS TO MEMBER:

  1. Use blue or black ink.
  2. Print clearly.
  3. Please complete and sign Part 1 and Part 2.
  4. Return the completed form to your Program Director.

PART 1 Member: Please Complete and Sign

  1. Name (Last, First, MI)
  2. Date of Birth (Month, Day, Year)
  3. Social Security Number
  4. Citizenship Status
    • I am a U.S. Citizen or National *
      *Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Nationals of the US include persons born in America Samoa, including Swains Island.
    • I am a Lawful Permanent Resident Alien of the United States **
      **Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident Card, INS Form I-551; (ii) an Alien Registration Receipt Card, INS Form I-551, (iii) a passport indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) an I-94 indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer eligibility to enroll in an AmeriCorps program.
  5. High School Status:
    • I have received a high school diploma or its equivalent
      OR
    • I agree to obtain a high school diploma or its equivalent before using my education award, and I did not drop out of elementary or secondary school to enroll in the program.
  6. Males 18-26 years old not yet registered with the Selective Service System: If you would like the Corporation for National and Community Service to provide the information on this page to the Selective Service System so that the agency may register you, please check this box.
  7. Current Address (All information will be sent to you at this address until you notify the Corporation of a change of address.).
    • Number and Street
    • City
    • State
    • Zip Code
    • Email Address
    • Home Phone
    • Business Phone
    • Ext
  8. Permanent Address (Name and address of person through whom you can always be reached once you leave the program.)
    • Last
    • First
    • MI
    • Number and Street
    • City
    • State
    • Zip Code
    • Email Address
    • Home Phone
    • Business Phone
    • Ext
  9. Have you ever previously enrolled in an AmeriCorps program?
    • No
    • Yes
      • If Yes, how many times:
  10. Have you ever been released 'for cause' from a term of service by this or any other AmeriCorps program?
    • No
    • Yes

By signing this enrollment form I agree, if asked, to provide information to verify the accuracy of my completed form. I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment or both under Section 1001 of Title 18, U.S.C., exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of my enrollment or other actions authorized by the Civil Fraud Remedies Act.

  • Member's Signature
    • Date

For Official Use Only


PART 2 Member: Please Answer the Following Questions

  1. What is your gender?
    • Female
    • Male
  2. Are you registered to vote?
    • Yes
    • No
    • Not sure
    • Not eligible
    • Prefer not to respond
  3. (Optional) Which of the following categories best describes your racial or ethnic origins? (Mark one or more from A and one from B)
    1. Race
      • American Indian or Alaska Native
      • Native Hawaiian or Other Pacific Islander
      • Black or African American
      • White
      • Asian
      • Other
    2. Ethnicity
      • Hispanic origin
      • Not of Hispanic origin
  4. Which one of the following best describes your marital status?
    • Single, never married
    • Married, living with husband/wife
    • Married, not living with spouse/legally separated
    • Widowed
    • Divorced
    • Prefer not to respond
  5. What is the highest level of education you have completed?
    • Less than high school completed
    • GED
    • High school graduate
    • Technical school/apprenticeship/vocational
    • Some college
    • Associates degree (AA)
    • College graduate
    • Some graduate school
    • Graduate degree
    • Professional degree (medical, law)
  6. Do you have a disability?
    • Yes
      • (Specify:
    • No
    • Prefer not to respond
  7. Are you a veteran of the United States Armed Forces?
    • Yes
    • No
  8. What are the two most important reasons why you decided to join this program?
    • To get an education award
    • To help other people/perform a community service
    • To be part of a national movement
    • To get a job/earn money
    • Friends have joined
    • To make friends
    • To learn about or work with different ethnic/cultural groups
    • Parents/teachers wanted me to join
    • To explore future job/education interests
    • To get involved in health issues
    • To get involved in education issues
    • To get involved in environment issues
    • To get involved in public safety issues
    • Other
      • Specify:
  9. How did you hear about this program? (Mark all that apply.)
    • Article
    • Advertisement in a newspaper/magazine
    • Guidance counselor/teacher
    • Parent/relative
    • Current or former AmeriCorps Member
    • Friend told me/friend applied
    • TV commercial
    • Radio commercial
    • The internet
    • AmeriCorps recruiter/representative
    • Received information in the mail
    • AmeriCorps program poster
    • Other
      • Specify:
  10. Privacy Act Information Release
    • Yes, I give the Corporation for National and Community Service permission to release my name, address, email and telephone number to the AmeriCorps alumni association.

Public reporting burden -- Estimated time to complete this form, including time for reviewing instructions and gathering and providing the information needed to complete the form, is 3 minutes for the Member section and 4 minutes for the Certifying Official section. Send comments regarding this burden or the content of this form to: Corporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. The Corporation informs the potential persons who are to respond to this collection of information that such persons are not required to respond to the collection of information unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1))

Privacy Statement -- In compliance with the Privacy Act of 1974, the following information is provided: The collection of this information is authorized by the provisions of the National and Community Service Act as amended by the National and Community Service Trust Act of 1993. The primary purpose of the information is to obtain from AmeriCorps program representatives their data to successfully enroll a member in a term of service and the education award program. The evaluative information will help the Corporation improve its programming and services to members. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed outside the Corporation without written permission. The Internal Revenue Service has determined that the education award is taxable in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue Code (28 U.S.C. 6011© and 6109) for use as a taxpayer identification number. Failure to disclose the SSN or any other information may result in a denial of your receiving an education award or it may delay the processing of your education award. In furtherance of the Corporation's efforts to ensure that the programs are inclusive of persons with disabilities, your Social Security Number may be released to the Social Security Administration to measure aggregate statistical data on the number of AmeriCorps members receiving disability-based benefits. If you do not wish your personal information to be included in this research, mark "prefer not to respond" under question 6.

OMB Approval No.: 3045-0006 Expires 07/31/2010


For Official Use Only


Member Social Security Number

DIRECTIONS TO CERTIFYING OFFICIAL:

  1. Use blue or black ink.
  2. Please complete and sign Part 3.
  3. Print clearly.
  4. If you are using WBRS or eSPAN, please provide the form to whoever enters data into that database for your program.

PART 3 Certifying Official: Please Complete and Sign

This section must be signed by an authorized certifying official. The program must designate certifying officials.
  1. Type of Enrollment (Mark only one.)
    • Full-time (1700 hours per year or 365 days for VISTA)
    • Half-time (900 hours in up to 2 years)
    • Reduced half-time 675 hours
    • Quarter time 450 hours
    • Minimum time/Summer 300 hours
  2. Is the member enrolling in an AmeriCorps education award only position (i.e. received no Corporation-funded living allowance or benefits)?
    • Yes
    • No
  3. Will the member receive a living allowance?
    • Yes
    • No
  4. Date of Enrollment: (mm/dd/yyyy)
  5. Type of Program
    • AmeriCorps National Direct
    • AmeriCorps State
    • AmeriCorps Tribe
    • AmeriCorps Territory
    • AmeriCorps National Civilian Community Corps
    • AmeriCorps Education Award Program
    • AmeriCorps Promise Fellows
    • AmeriCorps America Reads
    • AmeriCorps Governor's Initiative
    • Other
      • Specify:
  6. Program Information
    • Name of Program or AmeriCorps NCCC Campus
    • Operating Site I.D. Number
    • Number and Street
    • City
    • State
    • Zip Code
    • Business Phone
    • Ext

Signature of Certifying Official

  • Date

Name of Certifying Official (Please Print):

I understand that a knowing and willful false statement on this form can be punished by a fine punished by a fine or imprisonment or both under Section 1001 of Title 18. U.S.C.


For Official Use Only