Serve Louisiana AmeriCorps Member Application 22-23 Service Term

Serve Louisiana AmeriCorps Member

September 1, 2022- July 31, 2023
CONTACT INFORMATION
First and last name*
Pronouns

he/him/hisshe/her/herthey/them/theirOther
Email Address*
example@example.com
Phone Number*
Current Address*

Street Address

Street Address Line 2

City, State Zip CodeState / Province

Postal / Zip Code
Permanent Address

Street Address

Street Address Line 2

City, State Zip CodeState / Province

Postal / Zip Code
How did you find Serve Louisiana?
Eligibility Requirements

Please read the following questions carefully. If you are not sure whether or not you are eligible to serve, please contact the Serve Louisiana office with any questions.
1. You must be a US citizen, US national or Permanent Legal Resident to join Serve Louisiana. Do any of these designations describe your citizenship status?*

YesNo
2. Have you ever APPLIED to AmeriCorps or Serve Louisiana (previously known as Louisiana Delta Service Corps)? If no, skip to question 5.*

YesNo
3. Have you ever INTERVIEWED for AmeriCorps or for Serve Louisiana?

YesNo
4. Have you ever SERVED in AmeriCorps or Serve Louisiana?

YesNo
If yes, give service dates and name of corps:
5. Students will be accepted on a case-by-case basis as Serve Louisiana members will be expected to serve 40 hours per week and attend all team meetings, service projects, and retreats. Do you plan to be a student during Fall 2022 or Spring 2023?*

YesNo
6. Serve Louisiana members will receive a modest living allowance of $1,680 per month (before taxes). Would this allow you to meet your financial obligations?*

YesNo
7. The Serve Louisiana service term is September 1st - July 31st. Can you commit to these 11 months?*

YesNo
8. Serve Louisiana members must attend Serve Louisiana programming including team meetings and personal and professional development trainings. Can you commit to this requirement?*

YesNo
9. Serve Louisiana members will receive an education award of $6,495 which can be used towards student loans or future educations. Do you have a use for an education award ?*

YesNo
10. Serve Louisiana members commit to serving full-time at a partner organization (40 hours/ week). Can you fulfill this commitment?*

YesNo
11. Do you have reliable transportation?*

YesNo
12. Serve Louisiana members must consent to a criminal background check. See the consent form at end of the application for more information on disqualifying criminal convictions. Will you agree to a criminal background check?*

YesNo
13. Serve Louisiana members must be at least seventeen years of age. Do you meet this requirement?*

YesNo
14. Serve Louisiana members must have at least a high school diploma or G.E.D. Do you meet this requirement?*

YesNo
ADDITIONAL INFORMATION (OPTIONAL)

In compliance with federal civil rights laws, these questions are optional.Your responses will remain confidential.
Gender you identify with :

WomanManNon-binary/Third GenderOther
Date or Birth

MonthDayYear
Date
Categories that describe you:

White (ex: German, Irish, Polish, French, etc)Hispanic, Latino, or Spanish origin ex: Mexican or Mexican American, Puerto Rican, Colombian, etcBlack or African American (ex: African Am., Jamaican, Haitian, Nigerian, etc)Asian (ex: Chinese, Filipino, Asian Indian, Vietnamese, Korean etc)American Indian or Alaska Native (ex: Navajo Nation, Blackfeet Tribe, Mayan, Aztec, etc)Middle Eastern or North African (ex: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Pakistani etc) Native Hawaii orOther Pacific Islander (ex: Native Hawaiian, Samoan, Fijan, etc)Some other race, ethnicity, or origin
EMPLOYMENT HISTORY

List employers and jobs starting with the most recent:

	Place of Employment	Position/Title	Duties	Dates of Employment	Reason for Leaving	Point person and contact information

COMMUNITY INVOLVEMENT

List any community, social, faith-based, neighborhood, or professional projects and programs where you have served:

	Organization	Description of volunteer activities	Dates active	Point person and contact information

EDUCATION HISTORY

List schools attended, beginning with most recent:

	School and location	Area of Study	Degree and date achieved	Dates attended

Select All Preferred Positions:

Volunteer CoordinatorTechnology and Social Media CoordinatorProgram Outreach and Community Awareness CoordinatorProgram Development Coordinator
Select All Preferred Fields of Service:

Community DevelopmentFood Access Outreach/EducationMental Health and Substance Abuse PreventionHousing AccessEnvironmental ProtectionLegal ServicesYouth Education and Development
LOCATION AND ORGANIZATIONS OF INTEREST
List cities and organizations where you would like to serve:*
List any skills, interests, and hobbies:*
Employee Reference and contact information*
Community Reference and contact information *
Can be a community member, teacher, volunteer supervisor, faith-based leader, etc.
MOTIVATIONAL STATEMENTS

Please note that your responses in this section also serve as your writing samples.
1. Why do you want to become a Serve Louisiana/AmeriCorps member? *

0/500
2. We believe that we can learn from each other's experiences and beliefs. We expect to challenge each other and to be challenged. Tell us about a time when another person or group of people challenged your beliefs or ideals and how you handed it.*

0/500
3. Serve Louisiana members earn a small living allowance, roughly equivalent to the local poverty level. How do you anticipate this will affect you during the course of the year?*

0/500
4. Serve Louisiana involves corps members in the goal setting, planning, and facilitation of the monthly personal and professional development meetings. Why is leadership development important? How will you be a leader among your fellow Serve Louisiana members? *

0/500
5. What are your long-term goals, and how do you see that a year with Serve Louisiana would help to achieve them?*

0/500
6. During your service term, you will work as a team with your coworkers, with your fellow corps members, and with people living in your community. We work to help members understand and serve with guiding principles of open-mindedness, responsibility, and wholeheartedness. What might be challenging about working as a part of a team with these principles in mind? *

0/500
7. What does is mean to do good work?*

0/500
CERTIFICATION
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. I also understand that my selection for participation in some AmeriCorps programs may require drug testing. Background and security checks may also be conducted by some programs. 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. By signing below, I give the Corps permission to conduct a record check. Completion of this application does not guarantee an interview or position with AmeriCorps/Serve Louisiana.
Name*
Signature
Date

MonthDayYear
Date
National Service Criminal History Consent Form
I, agree to undergo the National Service Criminal History Check, which may include one or both of the following: Checks of state criminal history registries for locations where I’ve lived as well as where I will serve or work and/or an FBI fingerprint check. I also understand that acceptance into Serve Louisiana is subject to check results and that a candidate can be disqualified for any one of the following reasons: 1. Murder conviction 2. Required to be registered on a sex offender registry 3. False statement in response to inquiry about criminal history 4. Refusal to undergo the National Service Criminal History Check
I understand that I may review and challenge the factual accuracy of the results before action is taken to exclude me from the program. I understand that I will not assume the cost of performing any part of the three-part background check.
Name*
Signature
Date

MonthDayYear
Date
Should be Empty:

Serve Louisiana AmeriCorps Member

CONTACT INFORMATION

Eligibility Requirements

ADDITIONAL INFORMATION (OPTIONAL)

EMPLOYMENT HISTORY

COMMUNITY INVOLVEMENT

EDUCATION HISTORY

LOCATION AND ORGANIZATIONS OF INTEREST

MOTIVATIONAL STATEMENTS

CERTIFICATION

National Service Criminal History Consent Form