2014 – 2015
Enrollment Packet

2014-2015SOS Enrollment Checklist

Member Name: / T-Shirt Size:
Institution: / Date of In-Person Orientation:

Official enrollment begins AFTER a member submits a complete enrollment packet, including:

Signatures of member, site supervisor, and campus partner on all enrollment paperwork

Completed scan of the National Sex Offender Public Registry

Completed State Repository and FBI Fingerprint check

Required Paperwork

This checklist

AmeriCorps National Service Trust Enrollment Form

Member Agreement Authorization

Criminal Record Check Authorization Form

AmeriCorps Member Eligibility Verification Form

Photocopy of Proper Identification

Pre-service Reflection Questionnaire

Position Description and Site Agreement Plan

Please retain a photocopy of all paperwork you submit for your own records.

Please submit all enrollment paperwork as a complete package.



Member Agreement Authorization

Member Name: / Institution:

Before signing this authorization and certification, please make sure to review and understand the “Member Agreement” you received at SOS Orientation. If you have any questions, please contact your SOS campus partner.

Civil Rights Policy

The Corporation for National and Community Service (CNCS) is committed to treating all persons with dignity and respect, without regard to non-merit factors such as race, color, national origin, gender, sexual orientation, religion, age, disability, political affiliation, marital or parental status, or military service; and free of sexual, racial, national origin, religious or other harassment. Whether in CNCS offices or campuses, in other service-related settings such as training sessions or service sites, or at service-related social events, such harassment is unacceptable and will not be tolerated. (CNCS Civil Rights Policy, Paragraph 1)

For further information about the CNCS Civil Rights Policy, please review the Civil Rights Policy found on the Corporation for National and Community Service website.

Drug-Free Workplace Policy

In accordance with the Drug-Free Workplace Act of 1988, the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance (including alcohol) is prohibited in the member's workplace and program. Conviction of any criminal drug statute must be reported immediately to SOS staff. The member's participation in the Students of Service program is conditioned upon compliance with the notice requirements. Failure to adhere to this policy may result in disciplinary action, including termination.

Certification

By signing below, the member hereby acknowledges by his/her signature that s/he has read, understands, and agrees to all terms and conditions of the Member Agreement and has read and understands the Civil Rights Policy, Drug-Free Workplace Policy, and the List of Prohibited Activities. (If member is under 18 years of age, the members’ parent or legal guardian must also sign below) Also, by signing below, the member acknowledges that they are a student enrolled at a participating Students of Service campus, and participated in an in-person orientation about the Students of Service AmeriCorps program with a SOS campus partner before being enrolled into the Students of Service AmeriCorps program.

SOS Member:
Signature / Print Name / Date
Parent/Legal Guardian:
(Required for members under 18 years of age) / Signature / Print Name / Date
SOS Campus Partner:
Signature / Print Name / Date
Member’s Official Enrollment Date:
Publicity Information Release: I give Maryland-DC Campus Compact and the Students of Service program permission to use my program information (e.g. innovative programs, name/photograph associated with program information, etc.) for publicity and/or marketing purposes.
Initial if in Agreement: ______

Criminal Record Check Authorization Form

Part I: Authorization and Disclosure Statements

All students interested in enrolling in the Students of Service (SOS) AmeriCorps program will be subject to a criminal record check (National Sex Offender Public Registry, State Criminal History Repository, and FBI Fingerprint Check) before the member can be enrolled into the SOS AmeriCorps program. The member will need to sign and date the authorization section of this form and their SOS Campus Partner will complete the required NSOPR check. In addition, the SOS member will be responsible for scheduling and attending a fingerprinting appointment.

Authorization Completed by Member

Full Legal Name / Maiden Name
Permanent Home Address / City, County, State, Zip
Date of Birth / Sex / Social Security Number
State where college/university campus is located / State where service site is located

Disclosure Statements (Please choose one):

To the best of my knowledge, I hereby declare and affirm that I:

HAVE NOT been convicted, received a probation before judgment, received a non-criminally responsible disposition, and AM NOT the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.

HAVE NOT been convicted, received a probation before judgment, received a non-criminally responsible disposition, and AM the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.

HAVE been convicted, received a probation before judgment, received a non-criminally responsible disposition, and AM NOT the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.

HAVE been convicted, received a probation before judgment, received a non-criminally responsible disposition, and AM the subject of pending criminal charges. I further declare and affirm I am the above named person making this statement.

SOS Member Signature / Date

I understand that in the event that my criminal history and/or FBI check indicates that I am the subject of a criminal charge/charges, I will be required to provide both a written statement explaining the charge(s) and all supporting legal documents related to the charge(s)

I understand that if I have a past criminal history with a murder conviction, any type of sex offense conviction, am a registered sex offender, and/or am currently on parole or probation, I will not be permitted to enroll in the SOS program. All other offenses will be reviewed by the SOS Campus Partner, MDCCC office and/or the site supervisor on a case by case basis to determine my suitability to participate in SOS and/or to serve at a particular site.

SOS Member Signature / Date

Criminal Record Check Authorization Form

Part II: Authorizations and Certifications

In connection with my service with AmeriCorps and participation in the SOS program, I hereby authorize the SOS program to conduct a criminal background check on my behalf. I understand that this check could entail one or all of the following:

  • National Sex Offender Public Registry (NSOPR)
  • State Criminal History Repository (Maryland)
  • Criminal History Request (District of Columbia)
  • FBI Fingerprint

In addition, I understand that it is my responsibility to schedule an appointment to be fingerprinted for a check against the Maryland State Criminal History Repository and an FBI Fingerprint Check (along with the District of Columbia Criminal History Request if needed). I understand that the results of my background check will be shared with the Maryland-DC Campus Compact office and that my ability to serve as an SOS AmeriCorps Member is contingent upon the results of the background check. I understand failure on my part to consent to the review will result in cancellation of my enrollment in the SOS AmeriCorps program. Results are confidential, but may be shared with the Site Supervisor if necessary.

I am entitled to receive and review the information obtained, and challenge the factual accuracy of the information prior to cancellation of my enrollment into the SOS Program. I certify statements made by me on this form and in my enrollment paperwork are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that any false statements made herein could void my eligibility to serve with the SOS AmeriCorps program.

I also certify I will not serve a vulnerable population (children 17 years or younger, persons 60 years or older, or individuals with disabilities) without being accompanied at all times until all Criminal Record Checks have been completed, reviewed and approved and I have been informed of the approval by the SOS Campus Coordinator.

SOS Member Signature / Date


AmeriCorps Member Eligibility Verification Form

Only U.S. Citizens or people with permanent resident status qualify to participate in this AmeriCorps program. Please provide ONE of the following documents to the campus partner/program coordinator who will photocopy your official form of identification and sign in the blue box below. A photocopy of the official identification document must be kept in the member’s file. Any ONE of the below documents is adequate verification of eligibility.Please note that a driver’s license may not be used as the identifying document.

Proof of Eligibility
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. Dept. of State Form FS-240, Report of Birth Abroad of a Citizen of the United States
U.S. Dept. of State Form FS-545, Certificate of Birth-Foreign Service
U.S. Dept. of State Form DS-1350, Certificate of Report of Birth
INS Certificate of Naturalization (INS Form N-550 or N-570)
INS Certificate of Citizenship (INS Form N-560 or N-561)
Permanent Resident Card (INS Form I-551)
Alien Registration Receipt Card (INS Form I-551)
A passport indicating that the INS has approved it as a temporary evidence of lawfuladmission for permanent residence
A Departure Record (INS Form I-94) indicating that the INS has approved it as atemporary evidence of lawful admission for permanent residence
Other – If one of the above primary documentation 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

See August 22, 2003 Memorandum Re: Grants Management Guidance 02-02, Documentation of Member Eligibility and Member Record Retention for additional guidance.

Pre-Service Reflection Questionnaire

Member Name: / Institution:
  1. Aside from earning an Education Award, what motivates you to pursue a term of service with the Students of Service (SOS) AmeriCorps program through Maryland-DC Campus Compact?
  1. How does your participation in SOS relate to your professional/personal goals?
  1. In what ways do your professional/personal goals support lifelong involvement in your community?
  1. Once you are enrolled in the SOS program, no other student will be able to benefit from the education award allocated to you. Explain your commitment to completing a 300 hour term of service and what steps you will take to make sure the 300 hours are completed within one year.

PositionDescription/Site Agreement

Part I: Position Description and Member Development Plan
(Completed by SOS Member)

Member Name: / Institution:
Service Site: / (Full name of site – no acronyms)
  1. What are your specific duties and responsibilities as your service site? Provide details and examples.
  1. Explain the demographics of the K-12 student population you will be working with (i.e. percentage of students eligible for free and reduced lunch, ethnicity, family makeup, socioeconomic background, etc.).
  1. Describe two ways in which your service will positively impact your local community:

A.
B.
  1. What member development/training goals do you plan to pursue during your term of service that will help you better serve your community now and in the future?

A.
B.

Position Description/Site Agreement

Part II: Acknowledgement of Prohibited Activities
(Signed by SOS Member, SOS Campus Partner, and Site Supervisor)

As detailed in the 2013 AmeriCorps Grant Provisions, while charging time to the AmeriCorps program, accumulating service or training hours, or otherwise performing activities supported by the AmeriCorps program or the CNCS, staff and members may not engage in the following activities (see 45 CFR § 2520.65):

  1. Attempting to influence legislation;
  2. Organizing or engaging in protests, petitions, boycotts, or strikes;
  3. Assisting, promoting, or deterring union organizing;
  4. Impairing existing contracts for services or collective bargaining agreements;
  5. Engaging in partisan political activities, or other activities designed to influence the outcome of an election to any public office;
  6. Participating in, or endorsing, events or activities that are likely to include advocacy for or against political parties, political platforms, political candidates, proposed legislation, or elected officials;
  7. Engaging in religious instruction, conducting worship services, providing instruction as part of a program that includes mandatory religious instruction or worship, constructing or operating facilities devoted to religious instruction or worship, maintaining facilities primarily or inherently devoted to religious instruction or worship, or engaging in any form of religious proselytization;
  8. Providing a direct benefit to any—
  • business organized for profit;
  • labor union;
  • partisan political organization;
  • nonprofit organization that fails to comply with the restrictions contained in section 501(c)(3) of the Internal Revenue Code of 1986 except that nothing in this section shall be construed to prevent participants from engaging in advocacy activities undertaken at their own initiative; and
  • organization engaged in the religious activities, unless Corporation assistance is not used to support those religious activities;
  1. Conducting a voter registration drive or using Corporation funds to conduct a voter registration drive;
  2. Providing abortion services or referrals for receipt of such services; and
  3. Assisting any organization that has violated a Federal criminal statute;
  4. Performing any services or duties, or engaging in any activities, prohibited under the nonduplication, nondisplacement, or nonsupplantationrequirements relating to employees and volunteers;
  5. Such other activities as the Corporation may prohibit;
  6. Participating in activities that pose a significant safety risk to participants; and
  7. Fundraising including: for living allowance or other costs of the AmeriCorps program or an organization’s operating expenses orendowment; writing grant applications for AmeriCorps funding or for any other funding provided by the Corporation for National& Community Service; or writing grant applications for funding provided by any other federal agencies.

AmeriCorps members may not engage in the above activities directly or indirectly by recruiting, training,
or managingothers for the primary purpose of engaging in one of the activities listed above.


Position Description/Site Agreement

Part III: Site Agreement
(Completed by Site Supervisor)

Supervisor Contact Information:
Primary Site Supervisor:
Print Name / Title
Email Address: / Phone Number:
Secondary Site Supervisor:
Print Name / Title
Email Address: / Phone Number:
Service Site Organization:
Organization/Agency Name:
Address: / -
Street Address / City / State / 9-Digit Zip Code
Service Site is (please check all that apply): /  Non Profit /  School /  Govt. Agency /  Other:
The primary mission of your organization is:

Position Description/Site Agreement

Part IV: Campus Partner Checklist and Certification
(Completed by SOS Campus Partner)

Review of Part I: Position Description and Member Development Plan

The full name of service site (no acronyms) is written

Specific details and examples of direct service activities do not include any Prohibited Activities

Two specific positive impacts of SOS member’s service are provided

Specific details and examples of member development do not include any Prohibited Activities

SOS Member signed and dated Position Description

Review of Part II: Acknowledgmentof Prohibited Activities

SOS Member signed and dated list of Prohibited Activities

SOS Campus Partner signed and dated list of Prohibited Activities

Site Supervisor signed and dated list of Prohibited Activities

Review of Part III: Site Agreement

All Site Supervisor contact information is provided

All Service Site information, including nine-digit zip code, is provided

Site Supervisor signed and dated the Site Agreement