AmeriCorps Health Fellows Host Site Application

AmeriCorps Host Site Health Center Application Form 2026-2027

CCALAC is excited to offer the AmeriCorps Health Fellows program for the 2026-2027 program year. If your health center site would like to be a host site, please complete this form. If you have any questions, please e-mail Johnette Gonzalez, AmeriCorps Program Manager at jgonzalez@ccalac.org

Contact Information

Health Center Name(Required)

FIRST and LAST Name of individual completing this form(Required)

Title(Required)

Email(Required)

Enter Email Confirm Email

Phone(Required)

AmeriCorps Health Fellows

Please enter total # of requested AmeriCorps Health Fellows (Maximum of 5)(Required)

Please enter a number from 1 to 5.

AmeriCorps Health Fellows must serve in person. Will your health center be able to host the Health Fellows in person? (providing them the necessary desk space, computer, etc.)(Required)

What will be the job title of the position for the AmeriCorps Health Fellow(s)?(Required)

What Department(s) will the AmeriCorps Health Fellows work in? (Example: outreach, health education, case management, quality improvement, etc.)(Required)

What will the AmeriCorps Health Fellows' job duties? Please provide as much detail and information as possible. (For example: outreach, health education, case management, screenings, etc.). The Health Fellows must have direct interaction with patients (either through phone, in-person, etc.)(Required)

Who will supervise the AmeriCorps Health Fellows? (Please provide their name, titles, and e-mails)(Required)

Will the Health Fellow(s) need to travel between sites?(Required)

Please list the all anticipated health center location(s) - Address where the AmeriCorps Health Fellows will serve.(Required)

Please list any questions, request, or additional information you may have.(Required)

(Ex. Language needs, skill sets, experience.)

My health center is capable of paying the required health center site match of $28,500 per AmeriCorps Health Fellow (If selected to move forward, host site health center will be required to sign an MOU/MOA detailing payment).(Required)

YES

Signature (please sign to confirm you have permission from your health center to submit this application). If selected to move forward you will have to sign an MOU/MOA before interviewing applicants.(Required)