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708To learn more about Rockland County AmeriCorps, please call (845), 7307/7308, email at, or log onto our website at

PLEASE READ THIS INFORMATION BEFORE COMPLETING. • • • YEARS APPLICANTS MUST BE AT LEAST 17 YEARS OLD TO APPLY. Make a copy of your application for your personal records before you send it in. You may use additional sheets of paper to provide more detailed information that will not fit on this application form. (section You will need to write an essay (section VII) that should be typed and at least 250-500 words. Pay particular attention to content and mechanics (grammar, spelling, punctuation, etc.), as we will evaluate your essay based on these criteria. Two reference forms are enclosed in this packet. They are an important part of your application, and your application will not be considered without them. Completed references must be submitted with your application. They should not, if at all possible, be sent separately. For the references, select two people who you know well and are familiar with your personal background, education, employment, and/or professional skills. You should not ask a family coreference. member, neighbor, peer, classmate, co-worker, or friend to serve as a reference Consider asking work supervisors, clergy, teachers, counselors, coaches, advisors or someone else of a professional stature that is familiar with your motivation and community involvement. Send your application: Rockland County AmeriCorps Bureau c/o Rockland County Youth Bureau 18 New Hempstead Road New City, NY 10956






After your application has been received with all the necessary paperwork, we will contact you for an interview.



APPLICANT PROFILE (please print clearly in ink)

Name (last, first, middle initial) Social Security Number Date of Birth Place of Birth (city/state/country) Current Address City Permanent Address (if different) City Telephone Number (Home) E-mail Emergency Contact Name Phone State (cell phone) State Apt# Zip Apt# Zip Gender (Male or Female)

Are you a U.S. citizen, national, or lawful permanent resident alien? Yes No If you are a lawful permanent resident alien and you received your card after January 1987, what is your registration number and card expiration date? All applicants, once accepted into the program, must provide proof of citizenship (birth certificate or passport) or INS documentation.



Please 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 High School Diploma or GED Technical School/Apprenticeship Associate’s Degree Some college Bachelor’s Degree Graduate Degree Other (please specify)

Beginning with the most recent, list all schools attended. Include college, vocational school, high school, military and employment training.
Name of School (List most recent first) Location of School Begin Date MO/YR Date Completed MO/YR Major or Area of Study Type of Degree or Certificate Date Received or Expected



List and describe your organizational memberships and volunteer experience. Include social, school, professional, church and neighborhood programs and projects. Activities could include coaching, community outreach, community policing, tutoring, etc.
Name of Organization Involvement Beginning/End Dates Description of Activities/Position Contact Person and Phone Number



List and briefly describe the last two positions you have held. Begin with the current or most recent employment and work back from there. Include self-employment, internships/fellowships, home management, and full or part-time paid or unpaid work experience. (You may attach a resume instead, only if it addresses the information requested below.)
Name and Address of Employer Dates Job Title and Duties

Organization, city/state: Supervisor and Phone:

From: To:

/ /

Title: Duties:

Hours per week:

Organization, city/state: Supervisor and Phone:

From: To:

/ /

Title: Duties:

Hours per week:

Organization, city/state: Supervisor and Phone:

From: To:

/ /

Title: Duties:

Hours per week:




Listed below are skill areas that some programs find useful and may seek in applicants for AmeriCorps. Indicate the skill areas in which you have had training or experience, including volunteer or community service experience. Counseling Dorm Advisor EXAMPLE: Outdoor Projects Teaching/Education Counseling Computers Fine Arts/Crafts Public Health Recruitment/Outreach Trade Skills Youth Development Foreign Language Business Communications Conflict Resolution First Aid Fundraising Medicine Public Speaking Outdoor Education Writing/Editing Other (please specify)



Existence of a criminal conviction/adjudication may or may not, depending on the circumstances, disqualify you from consideration. However, misrepresentation of that record - lying or not telling the whole truth - will disqualify you. A background check will be conducted for each member prior to enrollment. Please answer the follow questions fully. 1. Have you ever been convicted, or adjudicated as a juvenile defender, of any criminal offense by a civilian or military court? (Do not include minor traffic violations) Yes No Specify the type(s) of conviction(s) and the date(s) 2. Are you now under charges for any offenses or are any civil suits or judgments pending against you? (Do not include charges for minor traffic offenses) Yes Date: Charge: 3. Are you now on probation or parole? Yes No No Place: Current Status:

Provide the name, address and phone number of the court, probation officer, or parole officer who we can contact to verify the above information. Name: Phone Number and Address Title:




You will need to write an essay answering all of the following questions, which should be typed and at least 250-500 words. Pay particular attention to content and mechanics (grammar, spelling, punctuation, etc.), as we will evaluate your essay based on these criteria. a. Using the Internet and/or AmeriCorps’ national website at, identify another, AmeriCorps program in the United States, describe what its mission is and how its projects have benefited the local community. How is it structured? What do you like about this program? What is your opinion about requiring students to volunteer in order to graduate? Do you think that service to the community is, or can be meaningful to the volunteer when it is required or expected?


c. “Sustainability” and living “Green” are concepts that have gained wider acceptance. What are your
thoughts on Sustainability? Is it practical? What do you think that you and people in your community can do to lead a more environmentally conscious lifestyle? 250(Attach a separate piece of paper with a response of at least 250-500 words.)



How did you find out about this program? (please specify) Newspaper Former Member Flyer (where?) School (what school?) What is the earliest date that you are available to begin service?

Church (where?) Friend (who?) Other

What is the latest date that you are able to finish service?



Your application must be certified with your original signature in ink.
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. Some programs may also conduct background and security checks. 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. To the extent permitted by state and local law in the jurisdiction where the Member is placed in service, the Member hereby agrees to allow RCA to conduct a criminal history record check on him/her if he/she is placed in service in an environment where he/she will have substantial direct contact with children or other individuals considered vulnerable by the Program. Applicants/Members have the right to be treated fairly and have their privacy respected. Applicants/Members will be given the opportunity to challenge the accuracy of information that RCA receives. Signature in the certification section of this application denotes consent for this background check. I hereby give my permission to the County of Rockland, Rockland County Youth Bureau, Rockland County AmeriCorps and Cornell Cooperative Extension of Rockland County to use any photos, slides, sketches or videos taken of me during an activity for publicity, advertising, and/or promotional purposes.



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.



Name: Relationship: Address:

Phone: (


Rockland County AmeriCorps

18 New Hempstead Road New City, NY 10956 845-708-7307 / 7308


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