Online Application DATE How did you hear about the CASA program? TV Radio Website Other CONTACT INFORMATION FIRST NAME(required) MIDDLE NAME LAST NAME(required) HOME TELEPHONE NUMBER:(required) WORK TELEPHONE NUMBER:(required) EMAIL ADDRESS:(required) HOME ADDRESS HOME ADDRESS:(required) COUNTY:(required) CITY:(required) STATE:(required) ZIP:(required) MAILING ADDRESS Mailing Address Same as home address MAILING ADDRESS:(required) COUNTY:(required) CITY:(required) STATE:(required) ZIP:(required) EMPLOYMENT INFORMATION EMPLOYER: POSITION/TITLE: Work Full-time Part-time Seasonal Length of employment: WORK ADDRESS: CITY: STATE: ZIP: EDUCATION AND EXPERIENCE(S) Please check the highest level completed: Some High School Post-Graduate High School Masters or Doctorate Some College College Graduate Do you speak a foreign language? Yes No Language(s): Check any training or experience (salaried or volunteer) in any of the following categories: (NOTE: None is required to be a CASA Volunteer) Child care Mental Health News/Media Law Drug/alcohol Child Development Counseling Writing/editing Arts/graphics Advertising Child Welfare Psychology Public speaking Public Relations Social Work Medicine Education Fund raising Criminology Please describe experiences checked above and share information about other volunteer service experiences: Have you ever worked for juvenile court? Yes No Have you ever worked for the Department of Family and Children Services? Yes No Have you ever been a foster parent? Yes No Have you ever sought treatment for a mental health problem? Yes No Have you or any members of your family ever had a case with or investigation performed by the Department of Family & Children Services? Yes No If Yes, please explain: List any charges, arrests, and/or conviction(s) (pending or closed), other than traffic violations: (Provide dates,county, state, and disposition of each case. An applicant having a charge or conviction for a crime involving a sex offense, child abuse, neglect, or related acts that would pose risks to children or the CASA program’s credibility is disqualified as a CASA volunteer. Applicants with other misdemeanor or felony charges or convictions that would not pose a risk to children or negatively affect the credibility of the CASA program will basis considering the time passed since the incident and the level of rehabilitation.) AVAILABILITY AND PREFERENCES When can you attend CASA training? BEST TIME OF DAY: AM PM BEST DAY OF WEEK: MO TU WE TH FR OTHER: Do you prefer to work with any particular age group? Yes No Do you have access to transportation? Yes No List any concerns you may have about the training requirements: REFERENCES Please list names and contact information of four (4) people (2 professionals – salaried or volunteer work – and 2 personal – no family members please). If currently employed, please list supervisor as your first reference. NAME: ADDRESS: CITY: STATE: ZIP: TELEPHONE CONTACT(S): EMAIL: RELATIONSHIP: NAME: ADDRESS: CITY: STATE: ZIP: TELEPHONE CONTACT(S): EMAIL: RELATIONSHIP: NAME: ADDRESS: CITY: STATE: ZIP: TELEPHONE CONTACT(S): EMAIL: RELATIONSHIP: NAME: ADDRESS: CITY: STATE: ZIP: TELEPHONE CONTACT(S): EMAIL: RELATIONSHIP: NOTE: It is important to list correct mailing addresses/email for your references so that we may contact them regarding your application to become a CASA volunteer. Please briefly answer the follow questions. (Two to four sentences each are sufficient.) Why do you want to be a CASA volunteer? What role do you believe society should play in protecting children versus assisting a overcoming hardships in order to function and ultimately live together as one unit? Please write an autobiographical statement. AFFIRMATION AND RELEASE I hereby affirm that all of the answers provided on my volunteer application are true. I understand that the information requested will be used only for the purpose of determining my suitability as a Court Appointed Special Advocate. I understand that this application does not ensure appointment as a CASA volunteer. I understand that completion of training does not guarantee that I will be assigned a case. After successful completion of my training, I further understand that I will be expected to serve a minimum of one year in the CASA program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit a written resignation to the program director with as much advance notice as possible. I am aware that I will be examining sensitive, confidential documents, reports and other material in my capacity as a CASA volunteer. I will discuss these matters only with those persons directly involved in the case at the Court or those who will be consulted for their professional knowledge or expertise. I will not divulge this confidential information to anyone else. I hereby authorize CASA and any law enforcement agency or other appropriate agency to receive any criminal history record information and state central registry information (from the Department of Family and Children Services) pertaining to me, which may be in files of any federal, state or local criminal justice agency in the United States, and to investigate my background to determine my fitness as a potential volunteer. This information may be requested and be received on a continual basis during the period of time that I am an active volunteer for the CASA program. I certify that the answers given in this application are true and complete to the best of my knowledge, and understand that if accepted into the program as a volunteer, any false or misleading statements on this application shall be grounds for dismissal. I agree Please complete the following information needed for background checks: FULL NAME(required) HOME ADDRESS(required) CITY: STATE: ZIP: SEX Male Female DATE OF BIRTH (MONTH/DAY/YEAR)(required) SOCIAL SECURITY NUMBER(required) Please check one: African American Asian Caucasian Hispanic Other If Other Specify : Submit Δ Like this:Like Loading...
Clayton CASA 