Youth in Action AmeriCorps
Civic Service Institute, Northern Arizona University
PO Box 6025, Flagstaff, AZ 86001
Phone: (928) 523-6395 / Fax: (928) 523-9189
AmeriCorps3@gmail.com
nau.edu/americorps
Member Application Part Two
Directions: Application Part Two should be completed after you have completed the online application
here: http://nau.edu/SBS/CSI/AmeriCorps/Prospective-Members/Apply/
Qualified individuals with disabilities and those from diverse backgrounds are strongly encouraged to
apply. We provide reasonable accommodations for qualified individuals upon request.
Applicant Name:
Minimum Qualifications:
I am a U.S. Citizen, National or Permanent Resident Alien who can legally work in the United
States
I will be at least 18 years old by August 31, 2016
I have or will obtain a high school diploma or the equivalent before using the Segal Education
Award
AmeriCorps Commitments:
If accepted as an AmeriCorps Member, I understand that I am committing to a total of 300, 450,
900, or 1700 hours, to be completed by 08/31/2016.
If accepted as an AmeriCorps Member, I understand that as a condition of service, I will have a FBI
fingerprinted background check and a National Sex Offender Registry search conducted prior to
beginning service. Some positions or situations may require additional screening.
If accepted as an AmeriCorps Member, I will attend the mandatory orientation, training, and
Esprit de Corps events. I understand that if I do not attend these events, I may be negatively
exited from the program.
Previous AmeriCorps Experience
Have you ever served in AmeriCorps before?
Yes
No If yes, please complete the following section:
Program Name:
Program Location:
Dates Served:
Did you successfully complete your AmeriCorps service?
Yes
No If not, why?
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Youth in Action AmeriCorps
Civic Service Institute, Northern Arizona University
PO Box 6025, Flagstaff, AZ 86001
Phone: (928) 523-6395 / Fax: (928) 523-9189
AmeriCorps3@gmail.com
nau.edu/americorps
Member Application Part Two
NAU AmeriCorps is federally funded and we must abide by the regulations governing national service
programs. In order to apply, you must be 1) a United States citizen, national, or lawful permanent
resident alien of the United States, 2) at least 17 years old at the start of your term, and 3) have obtained
the equivalent of a high school diploma before using your Segal Education Award.
Required Documentation
In order to prove that you are a citizen, national or lawful permanent resident, please provide a copy
of one of the following:
Copy of birth certificate
Copy of passport
Copy of Permanent Resident Card or Alien Registration Receipt Card
In order for us to complete I-9 verification that shows that you are legal to work in the United States,
please bring to our office, either:
United States passport AND Social Security Card
OR
Government issued picture identification or Resident Alien Card
AND Social Security Card
In order to verify your age, please provide a copy of one of the following:
Government issued picture identification (i.e. drivers license or passport) or Resident Alien Card
Copy of birth certificate
By signing this application, you are authorizing a state criminal registry check, FBI fingerprint check, and
the appropriate sharing of the results of such checks within our program. Selection for an AmeriCorps
position is contingent upon NAU AmeriCorps’ review of your criminal history, in any. To understand
NAU’s policy regarding background checks, review NAU HR policy 1.085.
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Youth in Action AmeriCorps
Civic Service Institute, Northern Arizona University
PO Box 6025, Flagstaff, AZ 86001
Phone: (928) 523-6395 / Fax: (928) 523-9189
AmeriCorps3@gmail.com
nau.edu/americorps
Member Application Part Two
Directions: Please check the boxes below to indicate your skills, interests, abilities, and availability. This section will be used
to help find a position that is a good fit for you. Please check all that apply.
Skills
Interests
First Aid Certification
Web page design
Graphic design
Public speaking
Writing
Marketing (including social
media)
Project management
Fluent in Spanish
Fluent in Navajo
Clerical (filing, copying, faxing)
Food service
Customer service
Child care
Counseling and/or social work
4-wheel driving
Coordinating volunteers
Tutoring and/or advising
Teaching groups of children
Accounting
Use a computer (PC)
Use a computer (MAC)
Use Microsoft Word to create
fliers
Enter data using Microsoft Excel
Use Microsoft Powerpoint to
make presentations
Strong math skills
Experience working with people
with disabilities
Experience working with diverse
populations
Other __________________
Other __________________
Other __________________
Working with
elementary school age
children
Working with teenagers
Working with senior
adults
Supervising others
Abilities and Availability
Have reliable
transportation
Have an Arizona Driver’s
License
Have a good driving record
Available all year long
(including December and
summer)
Small business
Available on weekdays
Native American culture
Available in the evenings
Native plants
Available on weekends
Sustainability and/or
Ability to work outside all
conservation
day in all weather conditions
Affordable housing
Available to travel for
Domestic violence
extended (10 days or more)
Human rights
assignments out of the local
Public health
area
College access
Ability to do physically
Education
strenuous work that includes
Adult literacy
lifting, bending, digging, etc.
Local history
Ability to stand for
Other _____________
extended periods of time
Other _____________
Ability to lift 50 lbs
Other _____________
Self-motivated
Ability to work
independently
Ability to work in a team
Can work with sensitive
data/confidential files
Other _______________
Other _______________
Other _______________
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Youth in Action AmeriCorps
Civic Service Institute, Northern Arizona University
PO Box 6025, Flagstaff, AZ 86001
Phone: (928) 523-6395 / Fax: (928) 523-9189
AmeriCorps3@gmail.com
nau.edu/americorps
Member Application Part Two
Community Focus Areas
Please rank the community focus areas with 1 being the area you are most interested in and 5 being the
area you are least interested in.
Youth Engagement in Service Learning and Leadership
Post High School Advising
Job Placement & Employment Opportunity
Financial Literacy
GED Program Development
Additional Questions
What are your expectations of AmeriCorps?
Are you currently registered to attend classes at NAU?
Are you currently registered to attend classes at CCC?
How did you hear about NAU AmeriCorps?
Yes
Yes
No
No
Certification
Directions: Your application must be certified with an original signature. Read the statement carefully before signing.
Unsigned applications and incomplete applications will not be considered for admission.
I certify that all 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 the
information provided herein may be used to process my application for acceptance into NAU AmeriCorps
and for other general routine purposes by local programs and/or the Corporation for National Service,
and it will not be disclosed outside of these entities without prior written permission.
___________________________________________________________
Signature
___________________________
Date
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