National Service Trust Enrollment Form

Completing this form enrolls an AmeriCorps member in the National Service Trust, which makes the member 

eligible for a Segal AmeriCorps Education Award upon successful completion of his or her term of service. It 

also provides AmeriCorps with basic demographic data. This form may be filled out on paper or electronically.

PART 1 // Member: Please Complete and Sign

1. Name __________________________________________________ __________________________________________________ ______________________

Last First MI

2. Date of Birth _______________________ ___________ ___________ 3. Social Security Number _____________ — __________ — _____________

Month Day Year

4. Citizenship Status  I am a U.S. Citizen or National *  I am a Lawful Permanent Resident Alien of the United States **

 I am an Asylee ***

*Citizens of the US include persons born in Puerto Rico, Guam, the US Virgin Islands, and the Northern Mariana Islands. Nationals of the

US include persons born in America Samoa, including Swains Island.

**Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident

Card, USCIS Form I-551; (ii) an Alien Registration Receipt Card, USCIS Form I-551, (iii) a passport indicating that the USCIS has approved 

it as temporary evidence of lawful admission for permanent residence; or (iv) a form I-94 indicating that the USCIS has approved it 

as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer resident status.

***You are an asylee if you have a Form I-94 with asylum granted stamp; form I-766 with Category “A5”, “A5”, or “A-5”; or an Order of 

the Immigration Judge granting asylum.

5. School Status

What is the highest level of education you have completed?

 Less than high school  High school diploma/GED  Technical school/apprenticeship/vocational

 Some college  Associates degree (AA)  College graduate  Graduate degree (e.g. MA, PhD, MD, JD)

If you do not have a high school diploma or its equivalent:

 I agree to obtain a high school diploma or its equivalent, and I did not drop out of elementary school or secondary school

to enroll in the program.

 I am exempt from the requirement to have a high school diploma, due to:

___________________________________________________________________________________________________________________________________

If you have some college, list the most recent school you attended:

___________________________________________________________________________________________________________________________________

If you have an Associate’s degree, list the school from which you received your most recent Associate’s degree:

___________________________________________________________________________________________________________________________________

If you have a Bachelor’s degree, list the school from which you received your most recent Bachelor’s degree:

___________________________________________________________________________________________________________________________________

If you have a graduate degree, list the school from which you received your most recent graduate degree:

___________________________________________________________________________________________________________________________________

6. Current Address (All information will be sent to you at this address until you notify AmeriCorps of a change of address.)

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Email Address ____________________________________________________________________________________________________________________

Home Phone _______________________________________ Business Phone _______________________________________ Ext __________________

7. Permanent Address (Name and address of person through whom you can always be reached once you leave the program.)

 Check here if permanent address is same as current address

Last _________________________________________________ First _________________________________________________ MI ___________________

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Email Address ____________________________________________________________________________________________________________________

Home Phone _______________________________________ Business Phone _______________________________________ Ext __________________

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Updated 09/2021

Expires 04/30/2025
8. Have you previously enrolled in an AmeriCorps, Silver Scholar, or Serve America Fellow Program? 

 No  Yes If yes, how many times: __________

9. Have you ever been terminated/released for cause by any AmeriCorps, Silver Scholar, or Serve America Fellow program?

 No  Yes

10. Segal Education Award Limitations

I understand that I may not receive more than the aggregate value of two full-time Segal Education Awards and that upon 

successful completion of the term of service, I will receive only that portion of the Segal Education Award for which I am eligible, 

which may be all or a part of a SegalEducation Award, or no Segal Education Award, pursuant to 45 CFR § 2526.55.

 No  Yes

PART 2 // Member Enrollment Certification

By signing this enrollment form I agree, if asked, to provide documentation to verify the accuracy of the information I have provided in 

this form. I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine 

or imprisonment or both under 18 U.S.C. § 11, exclusion from participation in federal programs, and forfeiture of benefits I may receive 

as a result of my enrollment or other actions authorized by the Civil Fraud Remedies Act, 31 U.S.C. §§ 381-3812.

Member’s Signature ____________________________________________________________________________ Date ______________________________

PART 3 // Member: Please Answer the Following Questions

AmeriCorps gathers information about sex, race, ethnicity, and other demographic information to ensure the agency has the most 

complete and inclusive data on national service participants. This information is confidential and will solely be used for data analysis 

to assist us in ensuring we serve all Americans equally. The information you provide will not be used in any way to determine or affect 

any federal benefit. Your responses are required in order to be enrolled as an AmeriCorps member, but will be kept confidential.

1. What is your sex?

 Female  Male  Nonbinary  Prefer not to answer

2. Are you registered to vote?

 Yes  No  Not sure  Not eligible

3. Which of the following categories best describes your racial origin? (check all that apply)

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

 Black or African American

 White

 Asian American

 Other

4. Which of the following categories best describes your ethnic origin?

 Hispanic or Latina/o  Not Hispanic or Latina/o

5. What is your military, veteran, or family member status? (check all that apply)

Note: All honorably discharged veterans qualify for nomination for the Presidents Volunteer Service Award.

 I am a Veteran

 I am an Active Duty Member of the U.S. Armed Forces 

 I am a Member of the National Guard or Reserve Component

 I am an immediate family member of a Veteran

 I am an immediate family member of an Active Duty Member of the U.S. Armed Forces

 I am an immediate family member of a National Guard Member or Reservist

 I am not in the military, a veteran or a family member of someone in the U.S. Armed Forces

6. How did you hear about this program? (check all that apply)

 Recruitment brochure

 College Resource Fair

 Facebook ad or on Facebook in general

 Twitter

 Other social media platform. 

Please specify: _____________________________________________

 AmeriCorps online recruitment system

 Job search web page

 Article (online, newspaper, or magazine)

 Advertisement in a newspaper/magazine

 Guidance counselor/teacher

 Parent/relative

 Current or former AmeriCorps member

 Friend

 TV commercial

 Radio commercial

 AmeriCorps recruiter/representative

 Received information in the mail

 AmeriCorps program poster

 State Service Commission

 Other. Please specify: ______________________________________

____________________________________________________________

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7. What is the highest level of education completed by your mother?

 Less than high school

 High school diploma or the equivalent, such as GED

 Some college but no degree

 Associate degree in college

 Bachelor’s degree

 Master’s, professional school, or doctoral degree

 Don’t know

 This question does not apply to me

8. What is the highest level of education completed by your father?

 Less than high school

 High school diploma or the equivalent, such as GED

 Some college but no degree

 Associate degree in college

 Bachelor’s degree

 Master’s, professional school, or doctoral degree

 Don’t know

 This question does not apply to me

9. Which category represents the total combined income of all members of your family during the past 12 months? 

This includes money or income received by members of your family who are 15 years of age or older.

 $24,999 or less

 $75,000 to $99,999

 $25,000 to $39,999

 $100,000 to $149,999

 $40,000 to $59,999

 $150,000 or more

 $60,000 to $74,999

 Don’t know

10. How confident are you that you could come up with $400 if an unexpected expense arose within the next month?

 Not at all confident

 Very confident

 Slightly confident

 Extremely confident

 Somewhat confident

 Don’t know

Public reporting burden—Estimated time to complete this form, including time for reviewing instructions and gathering and providing 

the information needed to complete the form, is three minutes for the Member section and four minutes for the Certifying Official 

section. Send comments regarding this burden or the content of this form to: AmeriCorps, 250 E Street SW, Washington, DC 20525. 

AmeriCorps informs the potential persons who are to respond to this collection of information that such persons are not required 

to respond to the collection of information unless it displays a currently valid OMB control number on this page of the form 

(see 5CFR 132.5(b)(2)(1))

Privacy Statement—In compliance with the Privacy Act of 1974, the following information is provided: The primary purpose of the 

information is to successfully enroll a member in a term of service and the Segal Education Award program. The evaluative information 

will help AmeriCorps improve its programming and services to members. Information may be shared with other agencies, such as the 

Social Security Administration, through computer matching agreements for the purpose of verifying identity and citizenship status 

information provided by you in this document. Your Social Security Number (SSN) is solicited under the authority of the Internal revenue 

Code (26 U.S.C. 611(b) and 619) for use as a taxpayer identification number. Failure to disclose your actual SSN or any other information 

may result in a denial of your receiving an Segal Education Award or it may delay the processing of your Segal Education Award.

All information obtained will be used only for official purposes, treated confidentially, and will not be disclosed unless there is a specific 

official need to know.

Page 3 of 4 OMB Approval No.: 3045-0006
PART 4 // Enrollment Certifying Official: Please Complete and Sign

1. Type of Program

AmeriCorps State & National:

 AmeriCorps National Direct

 AmeriCorps State

 AmeriCorps Segal Education Award Program

 AmeriCorps Tribe

 AmeriCorps Territory

 AmeriCorps VISTA

 AmeriCorps National Civilian Community Corps

 AmeriCorps Serve America Fellows

 Other (Specify): ____________________________________________

_______________________________________________________________

2. Type of Enrollment (check only one)

 Full-time (1700 hours per year, or 365 days per year for VISTA)

 VISTA Summer Associate (10-12 weeks)

 Half-time (900 hours in no more than 2 years)

 Half-time (900 hours in no more than 1 year)

 Reduced half-time (675 hours)

 Quarter-time (450 hours)

 Minimum time/Summer (300 hours)

 AmeriCorps Affiliate (100 hours)

3. Will the member receive a living allowance?

 Yes  No

4. Education Award Amount: ________________________________________________________________________________________________________

5. Program Information 

Name of Program (or AmeriCorps NCCC Campus) ________________________________________________________________________________

Operating Site I.D. Number _______________________________________________________________________________________________________

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Business Phone __________________________________________________________ Ext ______________________

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 

11of Title 18. U.S.C or other actions authorized by the Civil Fraud Remedies Act, 31 USC 381-3812. 

Signature of Certifying Official __________________________________________________________________ Date ______________________________

Name of Certifying Official (Please Print): ____________________________________________________________________________________________

For Official Use Only

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