Send Completed application to:
1 Smithfield Street, Pittsburgh, PA 15222
AMERICORPS APPLICATION
1. Name:Last / First / Middle
2. AmeriCorps members must be a United States citizen, U.S. National or Lawful Permanent Resident.
Are you a United States citizen, national, or lawful permanent resident alien? / Yes No
3. Age: / 17-18 19 or older
4. PLACE OF BIRTH:
City/State/Country
5a. I am applying for: Summer Term Fall (full year) Term Either
5b. I am applying for: Full Time Part Time Either
6. Have you been referred to us by a specific organization? / Yes No
If yes, which organization?
7. Do you have a specific organization in mind where you would like to serve? / Yes No
If yes, which organizations?
8. Earliest date you are available to begin service: / /
Month/Day/Year
9. Can you commit to serving the entire term? (Summer: about 2 months / Full Year: about 10 months) Yes No
If no, please explain:
10. CURRENT ADDRESS: All information will be sent to this address unless you notify us of a change.
NUMBER AND STREET (IF POSSIBLE, INCLUDE A NUMBER AND STREET ADDRESS WHEN USING A P.O. BOX)
CITY/STATE/ZIP CODE
Preferred Phone / ( ) - / E-Mail
11. Are you moving within the next six months? / Yes No / If yes, when*? / /
*Please notify us of new address at time of move. / MONTH/DAY/YEAR
EDUCATION
12. Check the highest level of education that you will have completed by the time you are planning to serve in AmeriCorps. (Check only one.)
Some high school Associate's degree Graduate degree
High school diploma or GED Some college Other (please specify):
Technical school/Apprenticeship Bachelor's degree
13. List all schools after high school that you have attended, including trade or technical schools, military training and employment training programs.
Name of School(List most recent first) / Location
of School
(City/State) / Dates Attended / Major
or Area
of Study / Type of
Degree or
Certificate / Date
Received or
Expected
From Mo./Yr. / To
Mo./Yr.
/ / / / /
/ / / / /
/ / / / /
/ / / / /
EMPLOYMENT
14. Beginning with the most recent position, list and briefly describe the last four positions you have held or your last ten years of employment you have held. Begin with the most recent position and go back ten years. Include self-employment, internships/fellowships, home management, and full- or part-time paid or unpaid work experience. You may attach a resume instead if it addresses the information requested below.
NAME AND ADDRESS OF EMPLOYER / DATES / JOB TITLE AND DUTIESA. Organization, City/State: / From: / / / Title:
MO./ / YR. / Duties:
Supervisor: Phone and email / To: / / / Reason for leaving:
MO./ / YR.
B. Organization, City/State: / From: / / / Title:
MO./ / YR. / Duties:
Supervisor: Phone and email / To: / / / Reason for leaving:
MO./ / YR.
C. Organization, City/State: / From: / / / Title:
MO./ / YR. / Duties:
Supervisor: Phone and email / To: / / / Reason for leaving:
MO./ / YR.
D. Organization, City/State: / From: / / / Title:
MO./ / YR. / Duties:
Supervisor: Phone and email / To: / / / Reason for leaving:
MO./ / YR.
Explain any period of time greater than six months not accounted for by your work/service history; or explain why you have no work history.
EXPERIENCE WORKING WITH YOUTH (Preference will be given to candidates with previous experience.)
16. Describe your experience working with youth. List your most recent activity first. Attach a separate sheet of paper if you need more space. Your experience does not have to be limited to a professional environment. For instance, you could list babysitting, teaching Sunday School, or helping to raise siblings.
A. DATES OF INVOLVEMENT: From: / / / To: / / / Hours per mo.:MONTH/YEAR / MONTH/YEAR
Description of Activity
Organization Name:
(if applicable) / # of Youth For Which You Were Responsible / Age(s) of Youth
B. DATES OF INVOLVEMENT: From: / / / To: / / / Hours per mo.:
MONTH/YEAR / MONTH/YEAR
Description of Activity
Organization Name:
(if applicable) / # of Youth For Which You Were Responsible / Age(s) of Youth
C. DATES OF INVOLVEMENT: From: / / / To: / / / Hours per mo.:
MONTH/YEAR / MONTH/YEAR
Description of Activity
Organization Name:
(if applicable) / # of Youth For Which You Were Responsible / Age(s) of Youth
COMMUNITY SERVICE (Previous service is not always a requirement.)
16. Describe how you have reached out to help others and/or how you have been involved in your own community. List your most recent activity first. Attach a separate sheet of paper if you need more space. Your involvement could include serving in neighborhood, school, religious, social, professional, or other volunteer groups; helping out with community service projects; or participating in less formal activities.
A. DATES OF INVOLVEMENT: From: / / / To: / / / Hours per mo.:MONTH/YEAR / MONTH/YEAR
Organization Name: / Location: / Phone: / () -
Description of Involvement: ______
B. DATES OF INVOLVEMENT: From: / / / To: / / / Hours per mo.:
MONTH/YEAR / MONTH/YEAR
Organization Name: / Location: / Phone: / () -
Description of Involvement: ______
PREVIOUS AMERICORPS EXPERIENCE
17. Have you previously interviewed for KEYS Service Corps? Yes No If yes, when?
Have you previously served in AmeriCorps? Yes No
Have you previously served in KEYS Service Corps? Yes No
How many times in each of the programs?
AmeriCorps*VISTA AmeriCorps*NCCC AmeriCorps *State and National
Program Name and phone:From: / / / To: / /
MONTH/YEAR / MONTH/YEAR
Did you successfully complete your term of service? Yes No
If no, why not?
SKILLS AND EXPERIENCE
18. In the space below or on a separate sheet of paper, provide any additional skills and experience that may be helpful in evaluating your application.
MOTIVATIONAL STATEMENT
19. We would like to understand more about you and your reasons for applying to KEYS Service Corps AmeriCorps. Take a few minutes and consider those experiences which have made you the person you are today. Please share with us one of these experiences and how it sparked your interest in working with youth and community service. If you need additional space, attach a separate piece of paper and limit your total response to 500 words.
CRIMINAL HISTORY
The AmeriCorps application process requires a criminal history check to ensure community members with whom we work are protected, particularly children, individuals with disabilities, and individuals over 60
years old.
We are investigating for past sexual offenses and violent crimes, or crime that would have a direct bearing on your service.
This background check will entail our search of the National Sex Offenders Registry and an FBI criminal history check, which will require you to be fingerprinted during Pre-Service Orientation.
You will not be permitted to begin serving without supervision until the history check is complete and you are cleared. If you are selected for further consideration, you will be given clearance applications and instructions at that time.
Applicant please read and initial the following statements:
As an applicant for an AmeriCorps member position, I understand and acknowledge that my acceptance as an
AmeriCorps member in the KEYS Service Corps AmeriCorps program is subject to the results of each of the following National Service criminal history elements:
ü PA State Police Criminal History Check
ü State Of Residence Criminal History Check if applicable
ü FBI Fingerprint Criminal History Check
ü PA Department of Public Welfare Childline Child Abuse Check
ü National Sex Offender registry
___I understand and acknowledge that my refusal to consent to the above checks makes me ineligible to serve.
___I understand and acknowledge that anyone listed or required to be listed on a sex offender registry is ineligible to serve.
___ I understand and acknowledge that anyone convicted of murder is ineligible to serve.
___I have reviewed the list of offenses on the reverse side of this page and understand that conviction of any of these offenses would make me ineligible to serve.
___I understand that making a false statement in connection with criminal history checks including but not limited to failing to disclose or lying about any arrests or convictions prior to the checks being conducted is grounds for making me ineligible to serve.
___Furthermore, I understand and acknowledge that National Service Criminal History Checks are only one element of the application screening process for an AmeriCorps position; and that positive results for all National Service Criminal History Checks do not guarantee that I will be placed as an AmeriCorps member.
___The results of your background checks will be kept confidential. Results will only be shared on a need-to-know basis.
Criminal History Barring Service with the KEYS Service Corps
Permanent Bars to KEYS AmeriCorps Service
A. Title 18 of the PA Consolidated Statutes:
Chapter 25 (relating to criminal homicide)
Section 2702 (relating to aggravated assault)
Section 2709.1 (relating to stalking)
Section 2901 (relating to kidnapping).
Section 2902 (relating to unlawful restraint).
Section 2910 (relating to luring a child into a motor vehicle or structure)
Section 3121 (relating to rape).
Section 3122.1 (relating statutory sexual assault)
Section 3123 (relating to involuntary deviate sexual intercourse)
Section 3124.1 (relating to sexual assault)
Section 3124.2 (relating to institutional sexual assault)
Section 3125 (relating to aggravated indecent assault)
Section 3126 (relating to indecent assault)
Section 3127 (relating to indecent exposure)
Section 3129 (relating to sexual intercourse with animal)
Section 4302 (relating to incest)
Section 4303 (relating to concealing the death of a child)
Section 4304 (relating to endangering the welfare of children)
Section 4305 (relating to dealing in infant children)
A felony offense under Section 5902 (b) (relating to prostitution and related offenses)
Section 5903 (c) or (d) (relating to obscene and other sexual materials and performances).
Section 6301 (a) (1) (relating to corruption of minors)
Section 6312 (relating to sexual abuse of children)
Section 6318 (relating to unlawful contact with minor)
Section 6319 (relating to solicitation of minors to traffic drugs)
Section 6320 (relating to sexual exploitation of children)
B. A felony offense under “The Controlled Substance, Drug, Device and Cosmetic Act” within the preceding five year period.
C. An out-of-state, federal, US territory or possession, or foreign nation offense similar to those listed above
Criminal History Barring Service with the KEYS Service Corps at School Host Sites
KEYS Service Corps AmeriCorps members serving at schools are bound by the additional restrictions as set forth by the Pennsylvania Department of Education. So in addition to the AmeriCorps statutes barring enrollment and of the other permanent bars above, the following offenses with convictions will also bar service at a school site.
In addition to the above permanent bars to school employment, Section 111(f.1) of the Pennsylvania School Code, 24 P.S. § 1-111(f.1), contains three provisions describing temporary bars including:
A. Under Section 1-111(f.1) (1) of the Pennsylvania School Code, if an individual is convicted of a felony offense of the first, second or third degree, other than those listed in Section 1-111(e), he will be barred from employment in Pennsylvania schools for ten years following the expiration of his sentence.
B. Under Section 1-111(f.1)(2) of the Pennsylvania School Code, if an individual is convicted of a misdemeanor of the first degree, he will be barred from employment in Pennsylvania schools for five years following the expiration of his sentence.
C. Under Section 1-111(f.1)(3) of the Pennsylvania School Code, if an individual is convicted more than once for driving under the influence of alcohol or a controlled substance, and the offense is graded as a first degree misdemeanor, he will be barred from employment in Pennsylvania schools for three years following the expiration of his sentence.
The Corporation for National and Community Service programs are available to all without regard to race, color, national origin, disability, age, gender, sexual orientation, religion, political affiliation, or other non-merit factors. Anyone believing he or she has been subjected to discrimination on these grounds by the Corporation for National and Community Service, AmeriCorps, or one of its grantees may contact our Office of Civil Rights and Inclusiveness at (202) 606-7503 or email at .
CERTIFICATION
If you choose to submit a paper application, your application must be certified with your original signature in ink.
By signing this application, or by submitting it electronically if applying on-line, 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 KEYS Service Corps, I may be required to submit to a physical examination, including drug 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 programs.
The principal purpose for requesting this personal information is to process your application for acceptance into an AmeriCorps program, 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.
______
SIGNATURE OF APPLICANT / DATE
Print Name:______
SIGNATURE OF PARENT/LEGAL GUARDIAN (if under 18 years of age)
Print Name: