2022-2023 Service to Improve Community Health Application Form

Thank you for your interest in the STICH AmeriCorps program! Please fill out our questionnaire to help us get to know you a little better.

Please note - submitting this application does not guarantee your selection as a STICH AmeriCorps Member. This application will take approximately 30 minutes to complete.

If you have any questions regarding the program, service sites, selection timeline, orientation, etc, please email us at mseverson@chcact.org.

Best of luck! We look forward to learning more about you!

Name: *

First Name Last Name

Phone Number: *

Area Code Phone Number

E-mail Address: *

Address: *

City State / Province

Postal / Zip Code

Upload Resume: *

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Please provide information for two professional references below. Reference #1 *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

How do you know reference #1? *

Reference #2 *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

How do you know reference #2? *

The STICH service term begins in early September. Are you available to start the program in September? If no, when is the earliest you would be able to begin the program? *

Yes No

The STICH program requires a full time dedication to national service for 10 months. This means you will serve 40 or more hours per week which may include evenings and weekends. Would you be able to meet these commitments? *

Yes No

The STICH program provides a small stipend of $16,502 before taxes, dispersed in even increments every two weeks during the 10 months of service. Do you feel you would be able to survive on the living allowance provided? *

Yes No

Do you possess personal, reliable transportation? *

Yes No

The STICH program requires service in a community health center, likely interacting with patients directly. Do you feel comfortable serving in the health center during COVID-19? *

Yes No

Do you speak any additional languages besides English? *

Why do you want to serve in the STICH AmeriCorps program? *

What are your top three professional strengths? *

If we were to meet your ex/current employer at a social event and them to describe you, what would they say in a few words? *

What skills do you hope to gain while serving in the STICH AmeriCorps program? *

What questions do you have about the STICH program? *

If selected for the STICH program, what areas of CT would you prefer to serve in? Select all that apply. *

New Haven Hartford Torrington Bridgeport Norwich Waterbury Cheshire