AmeriCorps Health Fellows Program Application

Name*

First Last

Please select your preferred pronouns.*

He/Him
She/Her
They/Them/Theirs

AmeriCorps is a federally funded program that requires program participants to be U.S. Citizens or Residents. Are you a U.S. Citizen or Permanent Resident Alien?*

Yes
No

If selected for the program, you must provide proof of citizenship or permanent residency. Do you have current documentation such as a valid PASSPORT or BIRTH CERTIFICATE and ID/Driver's License?*

Yes
No

How did you hear about this program?*

Date of Birth*

Gender*

The CCALAC AmeriCorps program is scheduled from October 2026 until July 31, 2027. Are you available to serve in AmeriCorps throughout this duration?*

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you able to travel site-to-site if needed?*

All travel will be conducted in Los Angeles County.

Cell Phone Number*

Email Address*

Enter Email Confirm Email

Do you speak and/or write in any languages other than English?*

Yes
No

Please list the languages and level (Basic, Proficient, Fluent)*

Are you moving within the next 3-6 months?*

Yes
No

Education (Check the highest level of education that you will have completed by the start of the program.)*

High school diploma
Some college
Associates degree
Bachelor’s degree
Graduate degree
Other

List the school for which you completed or will complete your highest level of education.*

Location (City, State)*

Major (Area of Study)*

Degree type (HS Diploma, AA,BA, BS, MPH)*

Date Degree Earned or Expected*

Motivational Statement*

We would like to understand more about you and your reasons for applying to the CCALAC AmeriCorps Health Fellows Program. Take a few minutes and consider the experiences which have made you the person you are today and describe how it sparked your interest in community health.

Community Service*

Describe your most recent involvement in community service. Explain why you decided to serve or get involved, and what you learned or how it made you feel. (Ensure this experience is listed on your resume as well)

Healthcare Experience*

Describe your experience working with medically underserved areas and/or medically underserved populations (low-income, homeless, etc.). Why do you wish you to serve in a program that works in these areas and with these populations?

At the end of this application you have need to upload a Resume and OPTIONAL Cover Letter. Please ensure that both are updated and accurately reflect your education, internships/fellowships, part-time/full-time work experience, extracurricular activities and any volunteer experiences.

Select the skill areas below in which you have experience and/or training and indicate how you gained those skills. If you do not have any, please write N/A. Example: took courses in college, helped family with their patient portal, was a peer counselor, etc.

Healthcare (including community and public health)*

Electronic Health Records Systems and/or Patient Portal*

Health Education:*

Behavioral Health:*

Case Management/Counseling:*

Community Outreach:*

Please complete the information below for 2 references that we can contact. Select people who you know well and who are familiar with your personal background, education, employment, and/or professional skills. You should not ask a family member or friend to serve as a reference. Consider asking work supervisors, professors, counselors, coaches, peers, classmates, co-workers, or someone else familiar with your motivation and community involvement.

Reference 1 Name*

First Last

How long have you known them:*

In what capacity do you know them: (Co-worker, supervisor, professor, etc.):*

Best Phone Number to reach them at:*

Email Address:*

Enter Email Confirm Email

Reference 2 Name*

First Last

How long have you known them:*

In what capacity do you know them: (Co-worker, supervisor, professor, etc.):*

Best Phone Number to reach them at:*

Email Address:*

Enter Email Confirm Email

All AmeriCorps programs require 3 criminal history checks to ensure that community members with whom AmeriCorps members serve are protected, particularly children, individuals with disabilities, and individuals over 60 years old. If you are selected for the program, you will be required to complete the State, FBI, and National Sex Offender background checks. You will not be permitted to serve until the checks are complete and you are cleared. The review process is not lengthy, and normally is completed within 1-2 weeks. Answer the following question. Existence of a criminal conviction or juvenile adjudication may or may not, depending on the circumstances, disqualify you from consideration. However, any intentional misrepresentation or omission will disqualify you. Do not include minor traffic violations.

Have you ever been convicted as an adult, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than a minor traffic violation?*

Yes
No

If yes, please explain:*

PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C 552a) requires that the following notice be provided to you: The authority for collecting information from you in this application is contained in 42 U.S.C 4952 of the Domestic Volunteer Service Act of 1973 as amended. You are advised that submission of the information is entirely voluntary, but the requested information is required in order for you to participate in AmeriCorps programs. The principal purpose for requesting this personal information is to process your application for acceptance into an AmeriCorps program, and for other general routine purposes associated with your participatiopn in an AmeriCorps program. These routine pruposes may include disclosure of the information to federal, state, local agencies pursuant to lawfully authorized requests, to present and former employers, references provided by you in your application, and educational institutions, for the purpose of verifying the information provided by you in your application. In some programs, the information may also be provided to fedral, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information will not otherwise be disclosed to entities outside of AmeriCorps and the Corporation for National and Community Service wihout your prior written permission. EQUAL EMPLOYMENT: The Community Clinic Association of Los Angeles County (CCALAC) and the AmeriCorps Health Fellows Program are an equal opportunity employer and provide equal employment opportunity to all people without regard to race, religion, color, sex, sexual orientation, marital status, national origin, age, mental or physical impairment or veteran status. Reasonable accomodations will be made for any applicant or AmeriCorps Health Fellow as requested. By typing in my name below, I certify that I have read and understand all of the above statements and that all of the statements and answers made by me in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith. Misinformation or omission of information could result in disqualification or termination as an applicant.

Upload Your Resume*

Accepted file types: pdf, Max. file size: 32 MB.

Please submit your resume as a PDF

Signature

2026-2027 AmeriCorps Health Fellows Program Application