Volunteer application

Step 1 of 3

Personal Information

Full Name(Required)

First Middle Last

Maiden

Sex(Required)

Full Home Address(Required)

Street Address City State ZIP Code

Has Previous Home Address?(Required)

Yes

(if less than 7 yrs. at present address please list the full address including the COUNTY you resided in).

Previous Home Address (if less than 7 yrs. at present address please list the full address including the COUNTY you resided in)(Required)

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

Home Phone(Required)

Cell Phone(Required)

Email Address(Required)

Times Easily Reached by Phone(Required)

Years in Area(Required)

Employer(Required)

How Long (at employer)(Required)

Job Title/Duties(Required)

Business Phone(Required)

May you be called at work?(Required)

Yes

Times Easily Reached at Work(Required)

Educational Level Completed(Required)

High School

College

Masters/Ph.D

Special Skills, Training, Hobbies(Required)

Professional / Civic / Social Affiliations(Required)

Volunteer Experience(Required)

Confidentiality/ Expectations/ Certifications

I understand that the information requested in this application will be used only for determining my suitability as a CASA Volunteer. Further, I understand that completion of training does not guarantee that I will be assigned a case. If I have successfully completed the training and have met all other requirements, and it has been determined that I am a suitable volunteer, I 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 my written resignation to the program coordinator with as much advance notice as possible.

I am aware of the sensitive and confidential nature of the official documents, reports and other material I will examine in my capacity as a CASA Volunteer. I will discuss these matters only with those persons directly involved in the case or who will be consulted for their professional knowledge and expertise.

I also understand that if for any reason it becomes apparent that my activities are contrary to the policies, goals and/or philosophy of CASA for Kids, Inc. and their desire to provide quality services to abused and neglected children, my services as a CASA Candidate or CASA Volunteer will be terminated.

I do submit the statements on this application are true, complete, and correct to the best of my knowledge. I do understand that falsification on this application can disqualify me from consideration or can result in dismissal later.

Certification of Suitability

I, the undersigned, hereby certify that I have no convictions resulting from a criminal offense (excluding minor traffic violations) especially alcohol or drug related charges at any time in the past three years nor is there any criminal action or investigation pending. I further certify that I, at any time, have had no convictions or charges pertaining to child abuse or child neglect nor have I ever been investigated by any social service agency regarding allegations of child abuse or child neglect.

Authority to Obtain Information

I hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize CASA for Kids, Inc. to obtain information concerning my suitability to become a volunteer for this agency from: the Dept. of Human Services; the Child Abuse Registry; the Department of Correction; the District Attorney's Office, Juvenile, Civil, and Criminal court records; the Department of Motor Vehicles; and/or police/sheriff records.

Print Full Name, including Middle Initial(Required)

Print Full Name, including Middle Initial

Date(Required)

Date

Signature(Required)

Signature

Personal Information

Training Availability & References

Reference 1 *

Reference 2 *

Reference 3 *

Confidentiality/ Expectations/ Certifications

Certification of Suitability

Authority to Obtain Information