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Marshfield Clinic Health System AmeriCorps
Member Application
2023-2024

Todays date

Open PDF document below, and read before proceeding. Right click to print the document.

Attachment:Expectations for Service in MCHS AmeriCorps.docx

First Name

* must provide value

Middle Name

Last Name

* must provide value

Pronouns (Select all that apply):

He, him, his

She, her, hers

They, them, theirs

Ze, Hir, Hirs

No pronoun

No preference

Other

Address

* must provide value

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Phone

* must provide value

Preferred Method of contact

* must provide value

Phone

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How did you hear about this AmeriCorps position? (Select all that apply)

* must provide value

AmeriCorps recruiter/representative

Guidance counselor/teacher/college professor

Parent/relative

Current or former AmeriCorps Member

Friend

Career Fair

TV or radio commercial

Digital ad

AmeriCorps.gov

Indeed.com

LinkedIn.com

Handshake.edu

JobsThatHelp.com

Social Media

Recruitment efforts by MCHS AmeriCorps program

Recruitment efforts by Host Site

Other

Please note that all applicants will be submitted for criminal background checks and DMV checks. Having a history in either does not mean you are not eligible.

Select the highest level of education you will have completed by the time you begin your service with AmeriCorps. (Members must have completed a minimum of a high school diploma or GED/HSED.)

* must provide value

High School/GED

Bachelors Degree

Technical School/Apprenticeship

Some Graduate School

Some College

Graduate Degree

Associates Degree

Other

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Other Education (please specify)

* must provide value

List any additional training completed such as military or trade/vocational school.

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Name of school and Declared Major(s) and/or Minor(s)

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Check all programs you are applying to (MCHS operates two programs. Each has a different focus and service area.)

* must provide value

Community Corps -Individuals are placed in non-profit organizations and government agencies across the state to address local public health priorities.

Recovery Corps - Individuals who are placed will undergo training in the Connecticut Community for Addiction Recovery (CCAR) model of recovery coaching and serve as recovery coaches. Recovery coaches will focus on reducing prescription drug, opioid, and other substance use disorders through one-on-one contact, outreach phone calls, and community education

Your answers to the following three questions will help us match you to the most appropriate sites available. Sites receiving your application will reach out to you directly if interested in learning more about you or to schedule an interview.

1. What geographic area of the state do you wish to serve in? Write "none" if available to relocate statewide

Area Preference 1:

Area Preference 2:

2. Do you have a specific site(s) that you are interested in or in contact with? For a list of current sites, visit our website at: https://www.google.com/maps/d/edit?mid=1FXEOmj7d3yZQ0a28QHHxYe91XCKNwoU&usp=sharing

Host site 1:

Host site 2:

3. Would you be open to other sites in your geographic area?

Yes

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If applicable, In the spaces below, share how you have reached out to help others and/or how you have been involved in your own community. In the description box, explain why you decided to help out or get involved, and what you received in return that is, what you learned or how it made you feel. Think in broad terms. Your involvement could include serving in neighborhood, school, youth, religious, social, professional, or volunteer groups; helping out with community service projects; or participating in less formalized activities such as assisting an elderly neighbor. Leave blank if you have not yet been involved

Approximate Start Date

M-D-Y

Approximate End Date

M-D-Y

Hours per Month

Organization Name (if applicable)

Location (City, State)

Phone

Description of Involvement

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Approximate Start Date

M-D-Y

Approximate End Date

M-D-Y

Hours per Month

Organization Name (if applicable)

Location (City, State)

Phone

Description of Involvement

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Have you previously served in AmeriCorps?

* must provide value

Yes

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Which program(s) were you previously involved with? (check all that apply)

* must provide value

AmeriCorps VISTA

AmeriCorps NCCC

AmeriCorps State and National Program

Location of AmeriCorps Program (City, State)

* must provide value

Previous Start Date of Service

* must provide value

M-D-Y

Previous end date of service:

* must provide value

M-D-Y

Did You Complete Your Term of Service

* must provide value

Yes

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If no, why not?

* must provide value

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Have you ever been employed by MCHS or served in a MCHS AmeriCorps program?

* must provide value

Yes

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Are you currently employed by MCHS?

Yes

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List and briefly describe the last three positions you have held. Begin with the current or most recent and go back ten years. Include self-employment, internships/fellowships, and full or part-time paid or unpaid work experience. (You may attach a resume instead if it addresses the information requested below.)

Optional: Upload Resume

Upload file

Employer/Organization Name

Employer City, State

Supervisor Name

Supervisor Phone or Email

Start Date

M-D-Y

End Date

M-D-Y

Hours per Week

Job Title

Duties

Reason for Leaving

Employer/Organization Name

Employer City, State

Supervisor Name

Supervisor Phone or Email

Start Date

M-D-Y

End Date

M-D-Y

Hours per Week

Job Title

Duties

Reason for Leaving

Employer/Organization name

Employer City, State

Supervisor Name

Supervisors Phone or Email

Start Date

M-D-Y

End Date

M-D-Y

Hours per Week

Job Title

Duties

Reason for Leaving

Why do you want to join AmeriCorps? What could you contribute to AmeriCorps? What do you hope to gain from serving as an AmeriCorps member?

* must provide value

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Answer the following questions fully. Existence of criminal conviction/adjudication may not necessarily disqualify you from enrollment into AmeriCorps. However, any intentional misrepresentation or omission will disqualify you. Do not include minor traffic violations.

Have you EVER been convicted of any criminal offense by a civilian court or military authorities?

* must provide value

Yes

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Have you EVER been adjudicated or held responsible as a juvenile offender of any criminal offense by a civilian court or authorities?

* must provide value

Yes

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Are you now under charges for any offenses or are any civil suits or judgments pending against you?

* must provide value

Yes

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Are you now on probation or parole?

* must provide value

Yes

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If you answered yes to any of the questions above, please provide additional information:

Date

* must provide value

M-D-Y

Place (City/State)

* must provide value

Charge

* must provide value

Action Taken

* must provide value

Court, Probation, or Parole Officer

* must provide value

Phone

* must provide value

Address

* must provide value

City

* must provide value

State

* must provide value

Zip

* must provide value

A conviction record will not necessarily disqualify you from enrollment into AmeriCorps. This information will be used only for job-related purposes and only to the extent permitted by applicable law. You may attach any additional information or explanation using the upload document link below.

Attach additional information (optional)

Upload file

Public notice of non-discrimination for participants in the Marshfield Clinic Health System AmeriCorps program:
In compliance with Corporation for National Service regulations and provisions, programs that receive federal funding, which includes Marshfield Clinic Health System AmeriCorps, must notify service recipients, applicants, program staff, and the public, including those with impaired vision or hearing, that it operates its program or its activity in accordance with requirements of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act.

All AmeriCorps programs prohibit any form of discrimination against persons with disabilities in recruitment, as well as in service. No qualified individual with a disability shall be denied the benefits of the program, be excluded from participation in services and activities or be subjected to discrimination by the program. No person shall be denied membership into AmeriCorps by reason of race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, disability, sexual orientation or age. Veterans are encouraged to apply. It is unlawful to retaliate against any person who, or organization that, files a complaint about such discrimination.

In addition to filing a complaint with local and state agencies that are responsible for resolving discrimination complaints, you may bring a complaint to the attention of the Corporation for National and Community Service. If you believe that you or others have been discriminated against, or if you want more information, contact:

Office of Civil Rights and Inclusiveness, Corporation for National and Community Service
1201 New York Avenue, NW
Washington, D.C. 20525
(202) 606-7503, (voice); (202) 606-3472 (TDD)
(202) 606-3465 (FAX); eo@cns.gov (e-mail)

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, including AmeriCorps*NCCC, will require a physical examination, including drug and alcohol testing. Background and security checks may also be conducted by some programs.

PRIVACY ACT NOTICE: The Privacy Act of 974 (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 126592 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 authorize 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.

* must provide value

Add signature

M-D-Y

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Marshfield Clinic Health System AmeriCorps
Member Application
2023-2024

EXPECTATIONS FOR SERVICE

APPLICANT INFORMATION

EDUCATION

SITE PREFERENCE

COMMUNITY SERVICE

Employment

MOTIVATIONAL STATEMENT

LEGAL

CERTIFICATION

You have selected an option that triggers this survey to end right now.

Marshfield Clinic Health System AmeriCorpsMember Application2023-2024

EXPECTATIONS FOR SERVICE

APPLICANT INFORMATION

EDUCATION

SITE PREFERENCE

COMMUNITY SERVICE

Employment

MOTIVATIONAL STATEMENT

LEGAL

CERTIFICATION

You have selected an option that triggers this survey to end right now.

Marshfield Clinic Health System AmeriCorps
Member Application
2023-2024