YouthBuild AmeriCorps Member Application

Page 1

Initial Application for Mile High Youth Corps’ AmeriCorps YouthBuild Program

Interest

Location

Position

Track Interest

ConstructionHealth and WellnessEither

General Information

First Name

Last Name

Date of Birth

Email Address

Phone Number

Alternate Phone Number

Mailing Address

P.O. Box or Number and Street

City

State

Zip

MHYC

How did you hear about Mile High Youth Corps?

Events

Event Others

Job Board Selection

Job Other

Have you ever served at MHYC before?

When?

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

Did you earn an education award?

Number of terms

Can you submit as a US Citizen, National or Lawful Permanent Resident?

YesNo

Page 2

YouthBuild Eligibility

Are you between 17 and 24 years old?

Do you have your GED or high school diploma?

Have you attended any school in the last 6 months?

YesNo

Which school?

Have you been pushed out or dropped out of high school?

Page 3

References/Alternative Contacts

Please provide us with the names and phone numbers of three references (not relatives) whom we can contact. Examples of acceptable references include: teacher, mentor, coach, neighbor, pastor, or supervisor.

Reference 1

Reference 1 Name

Reference 1 Phone Number

Reference 1 Occupation

Reference 1 Relationship to Applicant

Reference 2

Reference 2 Name

Reference 2 Phone Number

Reference 2 Occupation

Reference 2 Relationship to Applicant

Reference 3

Reference 3 Name

Reference 3 Phone Number

Reference 3 Occupation

Reference 3 Relationship to Applicant

Page 4

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 5

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 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