SCP Application-English

ALL questions with "red star" must be answered to complete this form successfully.

Name: *

Preferred Name (if applicable):

Date of Birth: *

Street Address: *

Address Line 2:

City: *

State: *

Zip Code: *

Home Phone Number:

Mobile Phone Number: *

Email Address: *

Gender: *

Male

Female

Marital Status *

Single

Married

Widowed

Other Other

City of Birth: *

Number of people living in your household: *

Have you ever been convicted of a felony or misdemeanor? *

Yes

No

If Yes, please provide an explanation of charges, date of offense, and status of the charges on a separate sheet to be included with this application.

Social Security Number: *

Drivers License or CA ID Number: *

Drivers License/ID Expiration Date: *

What is your mode of transportation *

If you selected "Own Vehicle" in the previous question, please list the vehicle's insurance and policy number:

As a AmeriCorps Seniors volunteer, you will be covered by accident and personal liability insurance plus a small death benefit while performing volunteer duties. This coverage is automatic and free of cost to you as long as you are an active, enrolled member of AmeriCorps Seniors FGP/SCP. Please provide the following information.

Emergency Contact:

Name *

Relationship *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Doctor Information:

Doctor's Full Name: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Annual Income:

If your spouse lives with you, please list all sources of income expected for both of you over the next 12 months.

Pension Income: *

Interest/Dividend Income: *

Net Rental Income: *

Retirement Income: *

Social Security SSI (Supplemental Security Income): *

Stock and Bond Income: *

Wages: *

Other:

If you put an income in the question above, please specify the income type:

How much do you spend on medical costs annually: *

Additional Information:

The following information will help AmeriCorps Seniors FGP/SCP match you with a volunteer opportunity.

Highest Grade of School Completed: *

Previous Occupations: *

Special trainings you have done: *

Hobbies/Talents: *

If you have experience serving children/adults with special needs, please list them: *

How did you hear about this program? *

Why do you want to participate in this program? *

Have you previously participated in a "Senior Companion" program? *

Yes

No

If you put "Yes" in the previous question, please list the program name you were in:

List two references other than relatives (name, address and phone number): *

Race/ethnicity: *

Have you ever served in the US military? *

Yes

No

All individuals who meet the AmeriCorps program guidelines and are eligible to work or serve for it may participate in the FG/SCP, regardless of race, color, national origin, sex, age, religion, sexual orientation, gender identity or expression, political affiliation, marital or parental status, genetic information, or past experiences, including whether or not they have served in the military, been convicted of a crime, or have disabilities.

The Corporation for National and Community Services requires all applicants to complete and pass fingerprint-based criminal background checks through the Federal Bureau of Investigation and the Department of Justice, and will also search the National Sex Offender Public Registry for the applicant’s name.

Applicant Signature: *

clear

Today's Date: * +

Interviewer/Reviewer:

Date Reviewed: +

Approver:

Date Approved: +

Additional Remarks: