National Association of Community Health Centers, Inc The Florida Community HealthCorps FLORIDA STATE APPLICATION (Please Print, Black or Blue Ink Only) An AmeriCorps State Program of the National Association of Community Health Centers and the Corporation for National and Community Service APPLICATION INSTRUCTIONS To apply for a position with the Community HealthCorps, simply complete and return the enclosed application to each program site in which you are interested (for detailed site information please see page 2 of the application). An applicant must be a U.S. citizen, U.S. national or lawful permanent resident who is at least 17 years old. There is no upper age limit. There are no minimum, formal education requirements. Those with less than a high school diploma or equivalency certificate, however, must agree to pursue one. This application asks you to determine the skills and experiences you offer as well as the reasons you hope to be selected. Consider each section carefully. Think about your roles in social service activities, membership in community organizations, academic experiences and personal talents. Take into account everything from your past and present. Your application, employment experience, professional and personal references help create a full picture of you and what you will bring to national service. Make sure this application reflects all the qualities that make you a good candidate for AmeriCorps and the Community HealthCorps. PROGRAM SITE LOCATION Please indicate your program site preference. Rank them in the order of your preference: Location City, State 1 ST Choice 2 nd Choice 3 rd Choice Please check the appropriate box for the AmeriCorps service term you wish to serve: Full-time (1700 hours) Part-time (900 hours) Quarter-time (450 hours) 1 of 7
The FL Community HealthCorps Program is a part of the nation-wide Community HealthCorps Program of the National Association of Community Health Centers. The FL Community HealthCorps operates in three program locations: Community Health of South Dade, Inc (based in Miami-Dade with placements throughout Miami-Dade & Broward County) A private, non-profit corporation CHI is a major provider of primary health care and mental health care to the residents of south Dade County. The organization, through its various sites, has successfully provided services to the medically underserved population of south Dade for over 27 years. The professional staff is composed of a full complement of multi-cultural medical, mental health and dental professionals, supported by nurses, technical, clerical and administrative staff. Contact: Natalie Hinson, Program Coordinator Mailing Address: 10300 SW 216 th Street, Miami FL 33190 Phone: 305-254-2018 Email: NHinson@hcnetwork.org Collier Community Health Centers (based in Immokalee with placements throughout Collier and Manatee County) CHSI was founded in 1977 through the collaborative efforts of community leaders for the purpose of improving the health of migrant and seasonal farm workers, rural poor, and other citizens of Collier County. Collier Health Services, Inc. ( CHSI ) is a private, not-for-profit safety net health care provider with 10 health care facilities located throughout Collier County. Contact: Irma Cox, Outreach Program Coordinator Mailing Address: 1454 Madison Avenue, Immokalee, Florida 34142 Phone: 239-658-3013 Email: icox@collier.org Tampa Community Health Centers (based in Tampa with placements in Hillsborough and Pinellas County) TCHC established on January 22, 1987 operates five health care centers in the north central Tampa area. In 1993, the Center began the first fully functional school-based primary care health center in Hillsborough County. Services provided include: adult and pediatric primary care, dental services, prenatal and gynecological services, school and work physicals and social services. Contact: Stephanie Theaker, Deputy Chief Operations Officer Mailing Address: 2402 East Martin Luther King, Jr. Blvd., Tampa, FL 33610 Phone: 813-866-0930 Email: STheaker@HCNetwork.org 2 of 7
APPLICANT INFORMATION First Last: Middle: Mr. Miss Social Security Number: Mrs. Ms. Is this your legal name? If not, what is your Preferred name? Birth Place: Birth date: Age: Sex: Yes No / / Are you a U.S. citizen, U.S. national or lawful permanent resident? Yes No M F Current street address: Current phone: Mobile phone: ( ) ( ) P.O. Box: City: State: ZIP code: Email Address: Permanent street address (if different from current address): Permanent phone: Mobile phone: ( ) ( ) P.O. Box: City: State: ZIP code: LEGAL Have you ever been convicted, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than minor traffic violations? Yes No Are you under any charges for any offense? Yes No Are you on parole or probation? Yes No If YES to any of the answers above please provide the following information. Note: You may also attach additional information. Date / / Location City State Charge Action Taken Court/Probation/Parole Officer Phone Address General Correspondence We will need to contact you frequently during the selection process. What is the best way to contact you? Current address Permanent address Current phone Permanent phone Email Other Written Correspondence We will need to mail you information during the selection process. What is the best way to contact you? Current address Permanent address Have you previously served in an AmeriCorps or with Community HealthCorps? Yes No If YES, please answer the following: AmeriCorps State & National AmeriCorps VISTA AmeriCorps NCCC Dates of Service: Program Name: / / to / / Program Location: Did you complete your term of service? Yes No If NO, please explain: 3 of 7
When are you available to serve as a Community HealthCorps member? Start Date / / End Date / / Do you speak or write any language other than English? Yes No If YES, please indicate the language(s) and your level of proficiency: Language 1: Proficiency: Basic Intermediate Advanced Fluent (conversational) Fluent (Written) Language 2: Proficiency: Basic Intermediate Advanced Fluent (conversational) Fluent (Written) OPTIONAL INFORMATION The information inside this box is optional and in no way will affect your selection 1. Please describe your ethnic background: Black/African American White/Caucasian (not of Hispanic origin) American Indian/Alaskan Native Native Hawaiian / Pacific Islander Hispanic / Latino Asian Other 2. Do you have any need(s) that require special accommodation(s)? Yes No 3. Does your family receive pubic assistance (food stamps, AFDC)? Yes No EDUCATION BACKGROUND Check the highest level of education that you will have completed by the time you are planning to serve in AmeriCorps. (Check only one.) Some High School High School Diploma / GED Trade / Technical School Associates Degree Some College Bachelor Degree Graduate Degree Other Beginning with the most recent, list all schools you have attended, including higher education institutions, high school(s), any trade or technical school, Job Corps, etc. Attach additional sheets if necessary. Name of School City/State Dates Attended Area of Study Type of Degree/Certificate COMMUNITY / VOLUNTEER INVOLVEMENT How have you been involved in your community? List and describe your organizational activities and volunteer service experience. 1. Dates of Involvement To: From: Hrs. per month: Group/Org. Name Activities/Role 4 of 7
2. Dates of Involvement To: From: Hrs. per month: Group/Org. Name Activities/Role 3. Dates of Involvement To: From: Hrs. per month: Group/Org. Name Activities/Role SKILLS AND SERVICE PREFERENCE SKILLS: Check the boxes below in which you have had significant training or experience, including volunteer or community service experience. Case Management Community Organization Public Speaking Recruitment Counseling Medical Disaster Response Domestic Violence Communication Mediation/Conflict Resolution Child Development / Child Care Teaching/Tutoring Translation/Interpretation Community Organization Computers/Technology Street Outreach Youth Social Work Community Center Work Parent Education POULATION PREFERENCE(S): Are there any specific populations you have an interest working in with? (please check all that apply) Adolescents Adults Children Homeless Gay/Lesbian/Bisexual Individuals with HIV/AIDS Seniors Women Migrant Farm Workers Rural Populations Non English Speakers Transgender POSITION PREFERENCE(S): Please indicate the positions you are most interested in. Please note: not all positions are available at all program sites. We will do our best to match your preferences with site needs. Health Educator Health Outreach Worker Community Health Advocate Volunteer Coordinator Patient Services Assistant Enrollment/Eligibility Specialist Dental Assistant Mobile Clinic Worker Support Group Coordinator Pre-natal Assistant Referral Coordinator Patient Advocate Translator/Interpreter Case Management Assistant Where ever I am needed Doula / Perinatal Educator Reach Out & Read Coordinator EMPLOYMENT HISTORY List and briefly describe the last four jobs you have held. Begin with the current or most recent. Include self-employment, internships/fellowships, home management, and full- or part-time paid or unpaid work experience. You may attach a resume instead only if it addresses the information requested below. Employer #1: Title Duties Supervisor Email Phone Dates / / to / / Employer #2: Title Duties Supervisor Email Phone Dates / / to / / 5 of 7 Employer #3: Title Duties Supervisor Email Phone Dates / / to / /
Hrs. per wk Hrs. per wk Hrs. per wk Reason for Leaving Reason for Leaving Reason for Leaving REFERENCES Please list two individuals whom we may contact as references. Use people who know you well, such as teachers/professors, guidance counselors, supervisors and community members. Name of Reference First Last Middle Position/Title Relationship Organization/Institution Address Phone Email Name of Reference First Last Middle Position/Title Relationship Organization/Institution Address Phone Email 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 will require a physical examination, including drug and alcohol testing. Background and security checks may also be conducted by some 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. Applicant Signature Date For Parent or Guardian of Applicants Under 18 Years of Age: I have reviewed this application and I authorize my son/daughter/legal ward to apply to AmeriCorps. Parent/Guardian Signature Date Name Relationship Phone Number Address Email It is against the law for organizations that receive federal financial assistance from the Corporation for National and Community Service to discriminate on the basis of race, color, national origin, disability, sex, age, political affiliation, or, in most cases, religion. It is also unlawful to retaliate against any person who, or organization that, files a complaint about such discrimination. In addition to filing a complaint with local and state agencies that are responsible for resolving discrimination complaints, you may bring a complaint to the attention of the Corporation for National and Community Service. If you believe that you or others have been discriminated against, or if you want more information, contact: Calvin George, National Director, Community HealthCorps National Association of Community Health Centers 7200 Wisconsin Avenue, Suite 210, Bethesda, MD 20814 Phone: 301-347-0400 ext. 2069 Fax: 301-347-0459 Email: cgeorge@nachc.com 6 of 7
or Office of Civil Right and Inclusiveness Corporation for National and Community Service 1201 New York Avenue NW, Washington, D.C. 20525 Phone: (202) 606-7503; TTY: (202) 565-2799 Fax: (202) 565-3465; Email: eo@cns.gov 7 of 7