Member Profile Form
For the next 10 months, you'll make a difference in lives and bring hope to communities across the nation through your service with AmeriCorps NCCC. We would like your families and home communities to know all about it! We also hope that, by sharing your service experiences in NCCC, we may inspire others to serve as well. The Community Relations Office will use this profile sheet; the information you provide may be used as quotes in press releases or special Corps Member articles. Please respond in complete sentences to all open-ended questions. If you have any questions, contact Community Relations Specialist Sandra Hajt, shajt@cns.gov.
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First Name *
Last Name *
City *
State *
Home Phone Number *
Email address *
Please select one: *
Required
Please select one: *
Required
Date of Birth *
What age will you be at the start of this program? *
Name of Parent(s)/Guardian(s)
City
State
If you have parent(s) or guardian(s) who live at a different address than what you've listed previously, please include that information here.
City
State
Educational background, including name and location of school(s) attended
Name of High School *
City *
State *
Graduation Month and Year (if graduated) *
High School Newspaper Name
High School Newspaper Email Address
Name of College/University
City
State
Graduation year (if graduated)
Degree or area of study
Sorority/Fraternity/Other Organization Affiliation
Other AmeriCorps Program, NCCC Term, or Military Branch (if applicable)
Organization
Year(s) Served
Location(s)
Do you have any immediate family members (parents, siblings, or grandparents) who have previous service experience (Peace Corps, Armed Forces, VISTA or other AmeriCorps programs)?
If Yes, please provide their name, name of service organization, the years served and if this person influenced your decision to join NCCC
Please respond in complete sentences to the following questions.
How did you hear about the National Civilian Community Corps (NCCC)? *
Why did you choose to do a term of national service? *
What were you doing before you decided to join NCCC?
What do you plan to do after you have completed your term of service?
Do you have any unique experiences or goals that you would like to share?
Local Media Contact Information
Please try to fill out as much of this as possible; you can call the newspaper directly and ask them for their contact information. We provide space for you to include multiple media outlets if you choose to. However, you are not expected to use all the spaces provided if you don't need it.
Name of Hometown Newspaper
City
State
Phone number of the newspaper
Name of the editor or newpaper contact person
Title of newpaper contact person
Email address of contact person
If unavailable, a fax number is acceptable.
Name of Hometown Newspaper
City
State
Phone number of the newspaper
Name of the editor or newpaper contact person
Title of newpaper contact person
Email address of contact person
If unavailable, a fax number is acceptable.
Name of Hometown Newspaper
City
State
Phone number of the newspaper
Name of the editor or newpaper contact person
Title of newpaper contact person
Email address of contact person
If unavailable, a fax number is acceptable.
Other Publications
Name of alumni/church/etc. newsletter
City
State
Name of the editor or contact person
Title of contact person
Email address of contact person
If unavailable, a fax number is acceptable.
Name of alumni/church/etc. newsletter
City
State
Name of the editor or contact person
Title of contact person
Email address of contact person
If unavailable, a fax number is acceptable.
If you or your parent(s)/guardian(s) are members of an organization that has a newsletter and you are interested in having press releases sent to it, please provide the information here.
Publication Name
City
State
Phone Number
Name of Contact
Title of Contact
Email address or Fax Number
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