DIAL/SELF AmeriCorps Program - Member Application 2018-2019
To apply for the DIAL/SELF AmeriCorps Program, please 1) complete this form, 2) submit your resume, and 3) submit 2 references.

Members must be at least 18 years-old and U.S. citizens, U.S. nationals or lawful Permanent Residents. DSAP protects against discrimination on the basis of color, race, ethnicity, nationality, sex, political affiliation, sexual orientation, gender identity or expression, religion, or disability. We make reasonable accommodations for interviews and service.

First and Last Name: *
Your answer
Address (at time of application): *
Your answer
City, State, Zip Code *
Your answer
Email Address *
Your answer
Phone: *
Your answer
MINIMUM QUALIFICATIONS
Are you at least 18 years old? *
Do you have a high school diploma / GED or equivalent? *
Are you a U.S. Citizen, U.S. National, or Lawful Permanent Resident? *
Do you have access to reliable transportation? *
Have you read our website? *
Have you ever enrolled in an AmeriCorps program before? *
If yes, what type of program? Check all that apply.
Have you ever been released for cause from an AmeriCorps, VISTA, or NCCC program?
How did you learn about the DIAL/SELF AmeriCorps Program?
Your answer
APPLICATION QUESTIONS
Responses should be at least a paragraph.
1) Please give a personal motivation statement that describes what you hope to gain through a year of service as a DIAL/SELF AmeriCorps member: *
Your answer
2) Please describe how you would like to incorporate arts or creative skills into your support of young people: *
Your answer
3) Please identify three qualities that would make you an effective member of the DIAL/SELF AmeriCorps team. Please provide examples from your personal or professional experiences that demonstrate these qualities: *
Your answer
4) Briefly describe any special skills you would like us to know about (examples: community organizing, zine-making, multiple languages, morale-boosting, group facilitation, outreach, writing, media production): *
Your answer
5) Is there anything else you would like us to know in considering your application?
Your answer
BACKGROUND CHECK POLICY
Satisfactory completion of a background check is a requirement for participation in DIAL/SELF AmeriCorps. Background checks are conducted by DIAL/SELF and include state criminal registry information checks in Massachusetts and in the applicant’s state of residence at the time they applied; FBI fingerprint check; and National Sex Offender Public Registry (NSOPW) check. If relevant information appears on the background check report(s), then DIAL/SELF may choose to complete a review process with the applicant. Any applicant listed or required to be listed on a sex offender registry or convicted of murder as defined and described in section 1111 of title 18, United States Code is ineligible to serve in any CNCS-funded service stream, including AmeriCorps. Background check information is kept in a locked file in the DIAL/SELF Administrative Office. Applicants will be given an opportunity to review their own background check information. In accordance with CORI regulations, DIAL/SELF does not release background check information to other agencies. Therefore, Site Partners follow their own policies regarding background checks for applicants, and applicants may be asked to complete an additional background check at their service sites.
I have read and understood this policy. *
Required
CERTIFICATION
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 1974 (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 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 authorized 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 Service without your prior written permission.
I certify that all of the statements made in this application are true, correct, and complete, to the best of my knowledge. *
Required
Date: *
MM
/
DD
/
YYYY
RESUME
Please email a resume that includes your education, work, and volunteer history. Email your resume to ascott@dialself.org. *
Required
REFERENCES
Please request that two people submit a reference in order to complete your application to the DIAL/SELF AmeriCorps Program. (Reference form link: https://goo.gl/forms/HJl7etPCEYHUm0902)

Select two people who know you well and who are familiar with your personal background, education, employment, and/or professional skills. Consider asking work supervisors, clergy, teachers, counselors, coaches, or someone else familiar with your motivation and community involvement.

Your application is not complete without these two references.

A link for your references will also be displayed when you submit this application.

I understand that it is my responsibility to request two references in order to have a complete application for the DIAL/SELF AmeriCorps Program. *
Required
Thank you for applying to the DIAL/SELF AmeriCorps Program!
For more information, feel free to visit our website: www.dialself.org/americorps.html or email: ascott@dialself.org or call: (413) 774-7054 ext. 101.
DIAL/SELF AmeriCorps serves the communities of Western Massachusetts in partnership with the Massachusetts Service Alliance, the State Commission on Community Service.
Submit
Never submit passwords through Google Forms.
This form was created inside of DIAL/SELF Youth & Community Services. Report Abuse - Terms of Service - Additional Terms