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AmeriCorps Member Application
Please complete the following application.
Personal Profile
First Name
Last Name
Current Address
All information will be sent to this address, unless you notify us of a change.
Address 1
Address 2
City
State
Zip
Home Phone
Cell Phone
Email
Are you moving within the next 6 months?
No
Yes
If yes, when:
Permanent Address
Please give the name and address of a person through whom you can always be reached.
First Name
Last Name
Relationship
Address 1
Address 2
City
State
Zip
Phone
Email
Member Eligibility
AmeriCorps members must be a United states citizen, U.S. National or Lawful Permanent Resident. Are you a United States Citizen, national, or lawful permanent resident alien?
No
Yes
If you are a lawful permanent resident alien and you received your card before January 1987, what is your Registration number?
Registration Number
Expiration Date
Date of Birth
Social Security Number
Availability
Do you have a particular Reservation location (county) in which you are interested serving?
No
Yes
If yes, please provide the county within the Reservation In which you would prefer To serve:
Select Location
Cherry Tree – Stilwell
Jay Early Head Start
Kenwood Head Start
Pryor Early Head Start
Red Bird Early Head Start – Stilwell
Salina PreK
Shady Grove Head Start
Tahlequah Early Head Start
Tahlequah Children’s Village
Wauhillau Early Head Start – Nowata
Please indicate your date of availability to begin work.
