3 2010 AC Enrollment Form

National Service Trust Enrollment Form

Completion of this form is required to enroll a serving member in the National Service Trust, making the member eligible for an education award upon successful completion of his or her term of service. It also provides the Corporation for National and Community Service with basic demographic data.

PART 1

Member: Please Complete and Sign

1 . Name

Last First MI

2 . Date of Birth 3. Social Security Number

Month Day Year

4. Citizenship Status I am a U.S. Citizen or National * I am a Lawful Permanent Resident Alien of the United States **

*Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Nationals of the US include persons born in America Samoa, including Swains Island.

**Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident Card, INS Form I-551; (ii) an Alien Registration Receipt Card, INS Form I-551, (iii) a passport indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) an I-94 indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer eligibility to enroll in an AmeriCorps program.

5. School Status I have received a high school diploma or its equivalent

I agree to obtain a high school diploma or its equivalent before using my educational award, and I did not drop out of elementary school or secondary school to enroll in the program.

6. Current Address (All information will be sent to you at this address until you notify the Corporation of a change of address.)

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

7. Permanent Address (Name and address of person through whom you can always be reached once you leave the program.)

Last

First

MI

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

8. Have you previously enrolled in an AmeriCorps, Silver Scholar, or Serve America Fellow Program? No Yes How many times? ­­

9. Have you ever been released 'for cause' by any AmeriCorps, Silver Scholar, or Serve America Fellow program? No Yes .

10. Education Award Limitations. I understand that I may not receive more than the aggregate value of two full-time education awards and that upon successful completion of the term of service, I will receive only that portion of the education award for which I am eligible, which may be all or a part of an education award, or no education award, pursuant to 45 CFR § 2526.55

PART 2

Member Enrollment Certification

By signing this enrollment form I agree, if asked, to provide documentation to verify the accuracy of the information I have provided in this form. I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment or both under Section 1001 of Title 18, U.S.C., exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of my enrollment or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Member’s Signature

Date

PART 3	Member: Please Answer the Following Questions

1.	What is your gender?
		Female						Male
2.	Are you registered to vote?
		Yes
		No
		Not sure
		Not eligible
		Prefer not to respond
3.	Which of the following categories best describes your racial (mark one or more) or ethnic origins (mark one)
	A.	Race
		American Indian or Alaska Native
		Native Hawaiian or Other Pacific Islander
		Black or African American
		White
		Asian
		Other
	B.	Ethnicity
		Hispanic or Latina/o
		Not Hispanic or Latina/o
4.	Which one of the following best describes your marital status?
		Single, never married
		Married, living with husband/wife
		Married, not living with spouse/legally separated
		Widowed
		Divorced
		Prefer not to respond
5.	What is the highest level of education you have completed?
		Less than high school completed
		GED
		High school graduate
		Technical school/apprenticeship/vocational
		Some college
		Associates degree (AA)
		College graduate
		Some graduate school
		Graduate degree
		Professional degree (medical, law)
6.	Are you a veteran of the United States Armed Forces?
		Yes				No
7a	Do you have difficulty with seeing, even if wearing glasses?
		No – no difficulty					Yes – some difficulty
		Yes – a lot of difficulty					Yes – Cannot do at all
7b	Do you have difficulty with hearing, even if using a hearing aid?
		No – no difficulty					Yes – some difficulty
		Yes – a lot of difficulty					Yes – Cannot do at all

7c	Do you have difficulty with walking or climbing steps?
		No – no difficulty				Yes – some difficulty
		Yes – a lot of difficulty				Yes – Cannot do at all
7d	Do you have difficulty remembering or concentrating?
		No – no difficulty				Yes – some difficulty
		Yes – a lot of difficulty				Yes – Cannot do at all
7e	Do you have difficulty communicating using your customary language, for example understanding or being understood?
		No – no difficulty				Yes – some difficulty
		Yes – a lot of difficulty				Yes – Cannot do at all
7f	Do you have difficulty with self-care, such as washing all over or dressing?
		No – no difficulty				Yes – some difficulty
		Yes – a lot of difficulty				Yes – Cannot do at all
8.	What are the two most important reasons why you decided to join this program?
		To get an education award
		To help other people/perform a community service
		To be part of a national movement
		To get a job/earn money
		Friends have joined
		To make friends
		To learn about or work with different ethnic/cultural groups
		Parents/teachers wanted me to join
		To explore future job/education interests
		To get involved in health issues
		To get involved in education issues
		To get involved in environment issues
		To get involved in public safety issues
		Other (Specify:					)
9.	How did you hear about this program? (Mark all that apply.)
		Article
		Advertisement in a newspaper/magazine
		Guidance counselor/teacher
		Parent/relative
		Current or former AmeriCorps Member
		Friend told me/friend applied
		TV commercial
		Radio commercial
		The internet
		AmeriCorps recruiter/representative
		Received information in the mail
		AmeriCorps program poster
		Other (Specify:					)
10.	Privacy Act Information Release
		Yes, I give the Corporation for National and Community Service permission to release my name, address, email and telephone number to the AmeriCorps Alumni Association.

Public reporting burden -- Estimated time to complete this form, including time for reviewing instructions and gathering and providing the information needed to complete the form, is 3 minutes for the Member section and 4 minutes for the Certifying Official section. Send comments regarding this burden or the content of this form to: Corporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. The Corporation informs the potential persons who are to respond to this collection of information that such persons are not required to respond to the collection of information unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1))

Privacy Statement -- In compliance with the Privacy Act of 1974, the following information is provided: The collection of this information is authorized by the provisions of the National and Community Service Act of 1990, by the National and Community Service Trust Act of 1993, and the Serve America Act of 2009. The primary purpose of the information is to obtain from AmeriCorps program representatives their data to successfully enroll a member in a term of service and the education award program. The evaluative information will help the Corporation improve its programming and services to members. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed outside the Corporation without written permission. The Internal Revenue Service has determined that the education award is taxable in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue Code (28 U.S.C. 6011© and 6109) for use as a taxpayer identification number. Failure to disclose the SSN or any other information may result in a denial of your receiving an education award or it may delay the processing of your education award. In furtherance of the Corporation’s efforts to ensure that the programs are inclusive of persons with disabilities, your Social Security Number may be released to the Social Security Administration to measure aggregate statistical data on the number of AmeriCorps members receiving disability-based benefits. If you do not wish your personal information to be included in this research, mark “prefer not to respond” under question 6.

OMB Approval No.: 3045-0006 Expires 07/31/2010

PART4

Enrollment Certifying Official: Please Complete and Sign

1.

Type of Enrollment (Mark only one.)

4.	Award
	award amount:
5.	Type of Program
		AmeriCorps National Direct
		AmeriCorps State
		AmeriCorps Tribe
		AmeriCorps Territory
		AmeriCorps National Civilian Community Corps
		AmeriCorps Education Award Program
		AmeriCorps Serve America Fellows
		AmeriCorps America Reads
		AmeriCorps Governor's Initiative
		AmeriCorps VISTA
		Silver Scholars
		Other (Specify):

Full-time (1700 hours per year or 365 days for VISTA)

Half-time (900 hours in up to 2 years)

Reduced half-time 675 hours

Quarter time 450 hours

Minimum time/Summer 300 hours

2.

Is the member enrolling in an education award only position (i.e. received no Corporation-funded living allowance or benefits)?

Yes

No

3.

Will the member receive a living allowance?

Yes

No

6. Program Information

Name of Program or AmeriCorps NCCC Campus

Operating Site I.D. Number

Number and Street

City

State

Zip Code

Business Phone

Ext

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001of Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Signature of Certifying Official			Date
Name of Certifying Official (Please Print):