AmeriCorps Member Application

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Page 1

General Information

First Name

Last Name

Preferred Name

Date of Birth

Email Address

Phone

Mailing Address

P.O. Box or Number and Street

City

State

Zip

MHYC Interest

Location

Program

Position

How did you hear about Mile High Youth Corps?

Please list specific name, website, key search word

Job Board Selection

Job Other

Name of High School / University / College

AmeriCorps members must be a United States citizen, U.S. national or lawful permanent resident. Individuals with only work authorizations or work VISAs are not eligible for AmeriCorps program. Are you able to submit proof?

Are you between 18 and 24 years old?

YesNo

Date You Will Be Available to Start Service

Page 2

Education & Experience

Do you have your GED or High School Diploma?

Please list your most recent full-time or part-time position, if applicable.

Company Name

Title/Position

Start Date

End Date

Responsibilities/Duties

Previous Experience

You are here applying for an AmeriCorps position and therefore have to disclose your previous AmeriCorps service.

Have you previously served in an AmeriCorps position?

YesNo

Previous service location

# of Terms

Did you earn an education award?

Have you ever served at MHYC before?

When?

Page 3

Demographic Information (optional)

As part of Mile High Youth Corps’ (MHYC) commitment to Diversity, Equity, and Inclusion work we request demographic information for accountability in maintaining an equitable workplace. The data collected will remain confidential and not be used to discriminate or make judgements regarding applications.

How long have you lived in Colorado?

How do you identify yourself? Race/Ethnicity. Select all that apply

Race/Ethnicity (Other)

How do you identify yourself? Gender

Gender (Other)

What are your preferred Pronouns?

Pronouns (Other)

Page 4

Read before signing

1. I affirm that all of the information provided in this application is true and accurate. I understand that the falsification of any information may be cause for immediate termination from the Mile High Youth Corps in the event that I am selected.

2. If I am selected, I will be required to provide satisfactory proof of identity and proof of citizenship within three days of the start date. Failure to admit such proof within the required time will result in termination.

3. In processing my application, I authorize Mile High Youth Corps and/or its agents to verify all answers, statements and information provided by me. I hereby release Mile High Youth Corps from any and all liability for any damage whatsoever arising from investigating and verifying the referenced information.

4. If I am selected, I am able to fully commit to serving the entire length of the program term and maintain a minimum of 90% level of attendance.

Applicant's Signature

Date

Parent/Guardian Permission

If applicant is under the age of 18, please have parent or guardian sign below:

I hereby give permission for the above named applicant to participate in the Mile High Youth Corps program.

Parent or Guardian's Signature

Date

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