Service Site Request Form (Returning Sites, 2008-2009 Term of Service)

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Submit this form no later than Friday, February 29, 2008. Please note: this form is for sites that are currently in the Straight Up AmeriCorps Partnership. If you are an organization that is interested in becoming a new AmeriCorps placement site, call 269-2019. Completion of this form does not guarantee AmeriCorps member placement. All positions are dependent on the availability of funding, and a site's ability to provide appropriate duties, supervision, and match.

Contact Information:

Site: *

Contact Person: *

Phone: *

Email: *

Address

Street Address

Address continued

City

State

Zip

Fax: *

Number of members requested to provide service at your site:

Preference will be given to sites that can provide service opportunities for full-time members, in teams of at least 2 members.

# of full time members *

Full-time members must serve 1700 hours from August 11, 2008 - June 26, 2009 (approximately 40 hours per week).

# of part time members *

Part-time members must serve 900 hours from August 11, 2008 - June 26, 2009 (approximately 20 hours per week).

Cash Match

Sites must be able to commit $8,000 per full time member and $4,000 per part time member to be considered for placement.

Cash match amount

Multiply the number of full time members x $8,000, and the number of part time members x $4,000 to calculate total match commitment.

Origin of cash contribution FederalStateLocalPrivateAvailability of funding is unknown at this time

Check all that apply if your cash contribution is coming from more than one source.

If you selected "unknown" above, when do you expect to know of funding availability?

If you checked "Federal" above, what amount of cash match is from Federal sources?

Priority will be given to sites with non-federal cash secured.

Straight Up AmeriCorps Program Design

All members must mentor 4 children at your site in a one to one setting for at least 1 hour per week per mentee. Describe how this will happen at your site: *

All members will be required to coordinate Health and Wellness activities for the children or youth at your site. This can include activities around nutrition, physical health, social well-being, drug and alcohol awareness, or service activities including a health and wellness component. Youth participants will complete a wellness awareness survey at the beginning of the year and again at the end of the program. Members should average 2.5 hours per day, 5 days per week on these activities. Describe how AmeriCorps members will accomplish this objective at your site. *

I understand that AmeriCorps members will be required to attend weekly/bi-weekly program trainings off-site on Fridays from 8:30 - 11:30 A.M. yes

Some members will need to be involved in volunteer recruitment and support activities, spending no more than an average of 2.5 hours/week on these activities. If your AmeriCorps member is engaged in these activities, they would help recruit and support both on-going and one-time volunteers to help out with activities for children at your site. Are you willing to have 1 or more of your AmeriCorps members spend time on this activity? * YesNo

Some members will need to participate in a limited amount of fundraising activities, seeking non-federal grants or donations to help fund specific activities for youth at your site. (Members cannot fundraise for your organization's operating costs or for the cash match to support their position.) Time spent on fundraising will be no more than 2.5 hours per week. Are you willing to have 1 or more of your AmeriCorps members spend time on fundraising activities? * YesNo

Straight Up AmeriCorps may need to set an earlier end date for the 2008-2009 term of service. The proposed end date is June 26, 2009. If AmeriCorps members are not available to serve at your site after this date, will this pose a hardship for your program? YesNo

Supervision

We have found, from experience, that the most successful AmeriCorps members have regular supervision at their service sites. We strongly suggest you plan to meet weekly with your AmeriCorps member to check in and assess progress, and to deal with challenges your member might be experiencing. Will you be able to arrange weekly meetings to provide member supervision and guidance? * YesNo

Who will be the AmeriCorps member's direct supervisor? *

Direct supervisor's contact information (if different from above)

Position Description

If you have more than one position description, and the positions are not exactly the same, click on "Add Another Response" below

What is the location of service? (If different from above)

What grade levels will your AmeriCorps members serve? *

What are the projected hours for this position. Include days of week, start time, end time, and lunch break. *

List any minimum qualifications required for this position

Are there any preferred skills needed for this position? i.e. foreign language, algebra, art...

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