Civicorps Corpsmember Academy Application Form With Cover Letter (Page 7 of 8) in pdf

Civicorps Corpsmember Academy Application Form With Cover Letter Page 7

CIVICORPS CORPSMEMBER ACADEMY

Physical Limitations Questionnaire

Corpsmember work is physically demanding and generally involves landscaping,

recycling, planting, clearing brush and/or fire hazards, building trails, restoring creeks,

cleaning flood channels, and painting. Most of this work is done outside and in all kinds

of weather.

Please indicate if you have difficulty performing the following types of tasks.

___Bending

___Pushing

___Pulling

___Walking

___Climbing

___Standing for long periods of time

___Squatting

___Lifting 50lbs or more

___Sitting for long periods of time

Please provide details about the difficulty you may have performing any of the tasks that

you marked above:

________________________________________________________________________

Are there other physical tasks that are difficult for you to complete? ___Yes ___No

If “yes”, please explain:

________________________________________________________________________

I understand that falsification of the above information is grounds for termination.

_____________________________

______________________________

Name

Date

_____________________________

Signature

Civicorps Corpsmember Academy Application Form With Cover Letter Page 7