2 AmeriCorps Enrollment and Exit Form

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 45 minutes. Send comments regarding this burden or the content of this form to: AmeriCorps, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. AmeriCorps 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 132.5(b)(2)(1)). The OMB Control Number for this information collection is 3054-0054, expiration date April 30, 2025.

National Service Trust Enrollment Form

Completing this form enrolls an AmeriCorps member in the National Service Trust, which makes the member eligible for a Segal AmeriCorps Education Award upon successful completion of his or her term of service. It also provides AmeriCorps with basic demographic data. This form may be filled out on paper or electronically.

PART 1

Member: Please Complete and Sign

1. Name Last First MI

2. Date of Birth Month Day Year

3. Social Security Number

4. Citizenship Status

I am a U.S. Citizen or National *

I am a Lawful Permanent Resident Alien of the United States **

I am an Asylee ***

*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, USCIS Form I-551; (ii) an Alien Registration Receipt Card, USCIS Form I-551, (iii) a passport indicating that the USCIS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) a form I-94 indicating that the USCIS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer resident status.

*** You are an asylee if you have a Form I-94 with asylum granted stamp; form I-766 with Category “A5”, “A5”, or “A-5”; or an Order of the Immigration Judge granting asylum.

5. School Status

What is the highest level of education you have completed?

Less than high school

High school diploma/GED

Technical school/apprenticeship/vocational

Some college

Associates degree (AA)

College graduate

Graduate degree (e.g. MA, PhD, MD, JD)

If you do not have a high school diploma or its equivalent:

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

I am exempt from the requirement to have a high school diploma, due to:

If you have some college:

Choose the most recent school you attended

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have an Associate’s degree:

Choose the school from which you received your most recent Associate’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a Bachelor’s degree:

Choose the school from which you received your most recent Bachelor’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a graduate degree:

Choose the school from which you received your most recent graduate degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

6. Current Address (All information will be sent to you at this address until you notify AmeriCorps 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.) Check here if same as current address.

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 terminated/released for cause by any AmeriCorps, Silver Scholar, or Serve America Fellow program? No Yes

10. Segal Education Award Limitations. I understand that I may not receive more than the aggregate value of two full-time Segal Education Awards and that upon successful completion of the term of service, I will receive only that portion of the Segal Education Award for which I am eligible, which may be all or a part of a SegalEducation Award, or no Segal 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 18 U.S.C. § 11, 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 U.S.C. §§ 381-3812.

Member’s Signature

Date

PART 3

Member: Please Answer the Following Questions

AmeriCorps gathers information about sex, race, ethnicity, and other demographic information to ensure the agency has the most complete and inclusive data on national service participants. This information is confidential and will solely be used for data analysis to assist us in ensuring we serve all Americans equally. The information you provide will not be used in any way to determine or affect any federal benefit. Your responses are required in order to be enrolled as an AmeriCorps member, but will be kept confidential.

1. What is your sex?

Female Male Nonbinary Prefer not to answer

2. Are you registered to vote?

Yes No

Not sure Not eligible

3. Which of the following categories best describes your racial origin? (check all that apply)

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Black or African American

White

Asian American

Other

4. Which of the following categories best describes your ethnic origin?

Hispanic or Latina/o Not Hispanic or Latina/o

5. What is your military, veteran, or family member status? (check all that apply)

Note: All honorably discharged veterans qualify for nomination for the Presidents Volunteer Service Award.

I am a Veteran

I am an Active Duty Member of the U.S. Armed Forces

I am a Member of the National Guard or Reserve Component

I am an immediate family member of a Veteran

I am an immediate family member of an Active Duty Member of the U.S. Armed Forces

I am an immediate family member of a National Guard Member or Reservist

I am not in the military, a veteran or a family member of someone in the US. Armed Forces

6. How did you hear about this program? (check all that apply.)

Recruitment brochure

College Resource Fair

Facebook ad or on Facebook in general

Twitter

Other social media platform. Please specify:

AmeriCorps online recruitment system

Job search web page

Article (online, newspaper, or magazine)

Advertisement in a newspaper/magazine

Guidance counselor/teacher

Parent/relative

Current or former AmeriCorps member

Friend

TV commercial

Radio commercial

AmeriCorps recruiter/representative

Received information in the mail

AmeriCorps program poster

State Service Commission

Other. Please specify:

7. What is the highest level of education completed by your mother?

• Less than high school

• High school diploma or the equivalent, such as GED

• Some college but no degree

• Associate degree in college

• Bachelor’s degree

• Master’s, professional school, or doctoral degree

• Don’t know

• This question does not apply to me.

8. What is the highest level of education completed by your father?

• Less than high school

• High school diploma or the equivalent, such as GED

• Some college but no degree

• Associate degree in college

• Bachelor’s degree

• Master’s, professional school, or doctoral degree

• Don’t know

• This question does not apply to me.

9. Which category represents the total combined income of all members of your family during the past 12 months?  This includes money or income received by members of your family who are 15 years of age or older.

• $24,999 or less

• $25,000 to $39,999

• $40,000 to $59,999

• $60,000 to $74,999

• $75,000 to $99,999

• $100,000 to $149,999

• 150,000 or more

• Don’t know

10. How confident are you that you could come up with $400 if an unexpected expense arose within the next month?

• Not at all confident

• Slightly confident

• Somewhat confident

• Very confident

• Extremely confident

• Don’t know

Privacy Statement—In compliance with the Privacy Act of 1974, the following information is provided: The primary purpose of the information is to successfully enroll a member in a term of service and the Segal Education Award program. The evaluative information will help AmeriCorps improve its programming and services to members. Information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verifying identity and citizenship status information provided by you in this document. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue Code (26 U.S.C. 611(b) and 619) for use as a taxpayer identification number. Failure to disclose your actual SSN or any other information may result in a denial of your receiving an Segal Education Award or it may delay the processing of your Segal Education Award.

All information obtained will be used only for official purposes, treated confidentially, and will not be disclosed unless there is a specific official need to know.

PART4

Enrollment Certifying Official: Please Complete and Sign

1. Program:

AmeriCorps State & National:

AmeriCorps National Direct

AmeriCorps State

AmeriCorps Segal Education Award Program

AmeriCorps Tribe

AmeriCorps Territory

AmeriCorps VISTA

AmeriCorps National Civilian Community Corps

AmeriCorps Serve America Fellows

Other (Specify):

2. Type of Enrollment (Mark only one.)

Full-time (17 hours per year, or 365 days per year for VISTA)

VISTA Summer Associate (1-12 weeks)

Half-time (9 hours in no more than 2 years)

Half-time (9 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 450 hours

Minimum time/Summer 30 hours

AmeriCorps Affiliate 100 hours

3. Will the member receive a living allowance?

Yes

No

4. Education Award Amount: ____________

5. Program Information

Name of Program or AmeriCorps NCCC Campus

Operating Site I.D. Number

Street Address

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 11of Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 381-3812.

Signature of Certifying Official Date

Name of Certifying Official (Please Print):

National Service Trust Exit Form

This form will end the term of an AmeriCorps member in the National Service Trust and report on the eligibility of the member for a Segal Education Award. It will also provide AmeriCorps with evaluation exit data. This form may be filled out on paper or electronically.

PART 1

Member: Please Complete and Sign

1. Name

Last

First

MI

2. Social Security Number

3. Mailing Address (Where the Segal Education Award should be sent, if mailed)

Number and Street

City

State

Zip Code

Email Address

Home Phone

Business Phone

Ext

4. For VISTA Volunteers only: I would like to

Complete my service as scheduled

Reenroll for another year

Extend my service for less than a year

Terminate my service early

AmeriCorps gathers information about education and disability status to ensure opportunities to serve are provided for people of all conditions. This information will be held confidentially and will solely be used for data analysis to assist us in ensuring we serve all Americans equally. The information you provide will not be used in any way to determine or affect any federal benefit. Under the Rehabilitation Act (Act) information on your disability status can only be used in connection with non-discrimination and affirmative action obligations. The information will be kept confidential in accordance with the Act’s provisions and the information will be used only in accordance with the Act.

5. Disability status.

The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.

Do you have one of the following? Check all that apply to you:

Deaf or serious difficulty hearing

Blind or serious difficulty seeing even when wearing glasses

Missing an arm, leg, hand, or foot

Paralysis, partial or complete (any cause)

Significant disfigurement, for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders

Significant mobility impairment, for example, use of a wheelchair, scooter, walker, or use of a leg brace to walk

Significant psychiatric disorder, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Intellectual disability (formerly described as mental retardation)

Developmental disability, for example, cerebral palsy or autism spectrum disorder

Traumatic brain injury

Dwarfism

Epilepsy or other seizure disorder

Other disability or serious health condition, for example, diabetes, cancer, cardiovascular disease, anxiety disorder, or HIV infection; a learning disability, a speech impairment, or a hearing impairment.

If you did not select one of the options above, please indicate why:

I have a disability or serious health condition but do not wish to specify my condition

I do not wish to answer questions regarding disability/serious health conditions.

None of the conditions listed above apply to me.

If you selected “Other disability or serious health condition”, please select any of the conditions listed below that apply to you. Please check all that apply.

Alcoholism

Cancer

Cardiovascular or heart disease

Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment

Depression, anxiety disorder, or other psychological disorder

Diabetes or other metabolic disease

History of drug addiction (but not currently using illegal drugs)

HIV infection/AIDS or other immune disorder

Kidney dysfunction, for example, requiring dialysis

Learning disabilities or ADHD

Liver disease, for example, hepatitis or cirrhosis

Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder

Morbid obesity

Nervous system disorder, for example, migraine headaches, Parkinson’s disease, or multiple sclerosis

Non-paralytic orthopedic impairments, for example, chronic pain, stiffness, weakness in bones or joints, or some

loss of ability to use parts of the body

Orthopedic impairments or osteo-arthritis

Pulmonary or respiratory impairment, for example, asthma, chronic bronchitis, or TB

Sickle cell anemia, hemophilia, or other blood disease

Speech impairment

Spinal abnormalities, for example, spina bifida or scoliosis

Thyroid dysfunction or other endocrine disorder

Other. Please identify the disability or health condition:

6. Do you receive Social Security disability benefits, such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?

Yes No Prefer not to respond

7. School Status

Has your highest level of education changed since you enrolled? Yes No

If yes, please answer the following questions:

What is your highest level of education?

Less than high school

High school diploma/GED

Technical school/apprenticeship/vocational

Some college

Associates degree (AA)

College graduate

Graduate degree (e.g. MA, PhD, MD, JD)

If you have some college:

Choose the most recent school you attended

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have an Associate’s degree:

Choose the school from which you received your most recent Associate’s degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a Bachelors’ degree:

Choose the school from which you received your most recent Bachelors’ degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

If you have a graduate degree:

Choose the school from which you received your most recent graduate degree

If school is not listed, provide name here

Type of degree, diploma, or certificate

8. Privacy Act Information Release

Yes, I give AmeriCorps permission to release the following information about me to an AmeriCorps Alumni Association (check all that apply):

Name

Address

Email

Telephone Number

0 No, I do not give AmeriCorps permission to release my information to an AmeriCorps Alumni Association.

9. Post Service Opportunities:

AmeriCorps would like to provide you with information and resources to help you stay engaged in service and connect with educational, professional, and alumni opportunities. Please check all that apply.

I am interested in connecting with other AmeriCorps alumni.

I am interested in learning more about educational opportunities and how to use my Segal Education Award.

I am interested in professional development trainings, resume-writing resources, and career opportunities.

0 Corps

I am not interested in this information and resources.

Certification of Service:

I certify that the time I reported to my program as program service hours is true and correct and did not include any service activities prohibited by law, regulation, or grant provisions. I agree, by signing this form, to provide, if asked, 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, USC; exclusion from participation in Federal programs; forfeiture of benefits I may receive as a result of participation in this program; or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Member’s Signature: Date:

Privacy Act Statement: AmeriCorps is required by the Privacy Act of 1974 (5 U.S.C. 552a) to tell you what personal information we collect via this website (e.g. name, contact information, demographics, education and employment history, criminal history, medical information) and how it will be used: Authorities – My AmeriCorps requests your personal information pursuant to 42 U.S.C. Chapter 129 - National and Community Service, 42 U.S.C. Chapter 66 - Domestic Volunteer Services, and Executive Order 9397, as amended.  Purposes – It is requested to (1) manage your application, service, and post-service benefits and (2) evaluate how to enhance AmeriCorps.  Routine Uses – Routine uses of this information may include disclosure to complete your background check, to process your payments, to manage and oversee your service, and other reasons consistent with why it was collected.  Effects of Nondisclosure – This request is voluntary, but not providing the information may limit your ability to become a Member, continue being a Member, or receive Member benefits.  Additional Information – The applicable system of records notice is CNCS-04-CPO-MMF-Member Management Files (MMF).

The Internal Revenue Service has determined that the Segal 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 (26 U.S.C. 6011(b) and 6109) for use as a taxpayer identification number. Failure to disclose your actual SSN or any other information may result in a denial of your receiving a Segal Education Award or it may delay the processing of your education award.

Exit information should be electronically submitted to AmeriCorps within 30 days of completion of service.

PART 2

Certifying Official: Please Complete and Sign

This section must be signed by an authorized certifying official. The program must designate certifying officials electronically to the

Corporation for National and Community Service.

1. Name of Program or AmeriCorps NCCC Campus

2. Operating Site I.D. Number

3. Hours of Service Performed

(not applicable for VISTA) Hours

4. Date of Completion of Term of Service

Month Day Year

5. Type of Enrollment

(Mark only one.)

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

VISTA Summer Associate (10-12 weeks)

Half-time (900 hours in no more than 2 years)

Half-time (900 hours in no more than 1 year)

Reduced half-time 675 hours

Quarter time 450 hours

Minimum time/Summer 300 hours

AmeriCorps Affiliate 100 hours

6. Segal Education Award Status:

Indicate whether or not the member is eligible for a Segal Education Award. Please be sure to follow AmeriCorps’s regulations in making this selection. If the Member is going to serve another term under the National Service Trust, a new National Service Enrollment Form

must be completed.

Eligible for entire Segal Education Award (member successfully completed service)

Eligible for partial Segal Education Award (member did not fully complete service for compelling personal reasons)

Not eligible for Segal Education Award (member did not fully complete service requirements)

Not eligible for Segal Education Award (member chose alternative benefit)

Not eligible for Segal Education Award (member dismissed for misconduct)

Not eligible for Segal Education Award.

Other (Specify):

7. Did the member perform satisfactorily (complete all assignments, tasks, and projects)?

Note, responding “No” may restrict future membership opportunities for this individual Yes

No

8. Certification of Service

I certify that to the best of my knowledge and belief, the time the above-listed member reported as AmeriCorps, Silver Scholar, or Serve America Fellow program service hours did not include any service activities prohibited by law, regulation, or grant provision;

That the member performed satisfactorily (completed all assignments, tasks, and projects); and that the hours of service performed indicated on this form for this service member are true and accurate.

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):