Rural Health Network of South Central New York

AmeriCorps Application

If you are interested in becoming an AmeriCorps member with the Rural Health Network of South Central New York, please complete the application below. You must be at least 18 to apply, and there is no upper age limit; however, applicant's target age range is between the ages of 18 and 25

You must also submit the contact information for 3 references or 3 letters of recommendation that are employment, education or volunteer service related. Email to dberchtold@rhnscny.org.

After you submit this application, you can expect to receive an email response from Danielle Berchtold (AmeriCorps Director for the Rural Health Network) within seven business days.

Visit our website: www.ruralhealthnetwork.org/americorps

Online Application Form
Please fill in the form below completely and click Send Application at the bottom.

First Name
Last Name
Date Of Birth (MM/DD/YY)
Are you a US Citizen or Permanent Resident?		Yes: No:
		Home (Permanent) Address
Street Address
City
State (two letters)
Zipcode
Current Phone Number(s)

Email Address
Best Time To Contact You? (AM/PM)
Date You Are Available To Start?
		Position
What Position(s) Are You Applying For?
Term
Why are you interested in serving with the Rural Health Network? What are your career goals and plans? What is your current educational level and what are your future educational goals and plans? Please list and describe your volunteer experience: Please list and describe your work experience: Have you ever served in an AmeriCorps Program? If so, please describe: Please tell us how you heard about the Rural Health Network AmeriCorps Program: Newspaper advertisement College or high school placement or volunteer office NYS Department of Labor Newspaper Article Corporation for National & Community Service Web Site Friend or Colleague Craigslist Other (please describe) Please remember to send contact information for 3 references in a separate email to dberchtold@rhnscny.org. Include as much information as possible, including name, title, organization, address, phone and email. Electronic Signature Agreement II understand that submission of this Rural Health Service Corps application constitutes affixation of my electronic signature. I verify that the information on this application accurately represents my candidacy and is true to the best of my knowledge. In the event of my active candidacy in the program, I authorize the Rural Health Network of South Central New York and the Rural Health Service Corps program staff to investigate any statement contained in this application, to conduct necessary reference and criminal background checks to determine my qualifications.