MHFA Corps Host Site Application
1. Host Site Information
Name of Organization *
Your answer
Address *
Your answer
City/Town *
Your answer
State/Province *
Your answer
ZIP/Postal Code *
Your answer
Federal EIN # *
Your answer
Geographic Area Served *
Your answer
2. Site Supervisor
First Name *
Your answer
Last Name *
Your answer
Title *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Willing to complete a background check? *
Able to provide weekly one-on-one supervision for the AmeriCorps member? *
Describe site supervisor's credentials and supervisory experience. *
Your answer
3. Experience / Partners
Does your agency plan to work with any partners? If yes, please describe partners. *
Your answer
Describe experience your agency has with Mental Health First Aid, if any. Include any involvement your agency has with Project AWARE initiatives. *
Your answer
Describe the mental health needs in your community. *
Your answer
Describe experience your agency has with mental health programs and initiatives. *
Your answer
Does your agency have union employees engaged in same or substantially similar work as the AmeriCorps member? *
If yes, you will be required to provide written labor union concurrence from your local representative *
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