PLEASE PRINT LEGIBLY CASA is an Equal Opportunity Organization. You must be at least 21 to become a CASA Volunteer. Name: Aliases/Maiden Name: Current Address: Residence address, if different: City, State, ZIP: Thank you for your interest in becoming a voice for an abused or neglected child in your community. Please complete and execute this application and return to the CASA office. You may contact our offices with any questions. (256) 765-0041 How long have you lived in Alabama? If you have lived in any other State, Country or County in Alabama, please list said residences below, along with the year which you lived in said place: (you may attach additional pages if necessary) Home phone: Work phone: Cell phone: E-mail address: Social Security Number: Date of birth: / / Race: Ethnicity: Age: Do you have a preference to work in Lauderdale or Colbert County? Do you have an Alabama Drivers License? If so, list DL#: Do you have a Drivers License from another State? If so, list the issuing State and number: *CASA will require a copy of your current driver s license. Do you have your own vehicle for transportation? Do you have personal vehicle insurance? *CASA will require current proof of personal vehicle insurance. Are there any problems with your securing your own transportation in your work as a CASA Volunteer? CASA Volunteers cannot bring any non-casa person with them on any visit, except an attorney or social worker assigned to the case. CASA persons include staff or co-volunteers approved by staff. CASA Volunteers are NOT allowed to transport children and/or children s family members. 1
Marital Status: If married, name of spouse: Spouse s employment status: Spouse s Date of Birth: How does your spouse feel about you working as a CASA Volunteer? Former Spouse(s) and DOB: Children s Names and Ages: Name: DOB: Age: Name: DOB: Age: Name: DOB: Age: Name: DOB: Age: Emergency contact (friend or relative nearest you): Name: Phone(s): Relationship: Employment status: (check one) Employed full-time Employed part-time Student Unemployed, seeking employment Unemployed, NOT seeking employment Retired Career type: (circle one) Teacher Attorney Health Care Professional Government/military Other education professional Other Career: If employed, give name of employer: Immediate supervisor: Position: Weekly Hours worked: Length of employment: Does your employer understand that you may need to take time from work or be allowed flex time for certain functions of the CASA Volunteer position? Yes No 2
If you have worked in any other Country, State or County in Alabama, please list same below, along with the year which you worked in each place: (you may attach additional pages if necessary) If retired, give name of company last worked for: Position held: Dates of employment: Educational background: Highest level of education completed: Previous or current volunteer experience: 1. 2. 3. Experience working with children, child welfare, or the court system: 1. 2. How did you become aware of CASA? (circle one) Friend Radio Newspaper TV Community Program/Speaker Other What attracted you to becoming a CASA Volunteer? What are your expectations for being a CASA Volunteer or working with the CASA program? 3
In addition to fact-finding, would you be interested in assisting CASA in any of the following capacities? Please check all that apply. General clerical work in the office Speaking Engagements Fundraising/Campaigns Recruitment Special Events Writing Engagements Hospitality (food planning/preparation) for special events and training classes Do you have access to a computer with Internet? Yes No Tell us about your computer skills. What special talents do you bring to CASA? Would you be comfortable going to the homes of strangers and asking very personal questions? Yes No Would you be comfortable talking with children who may be hostile or withdrawn? Yes No Would you be able to meet and talk with people who are experiencing serious problems in their homes without being judgmental? Yes No Can you work with people of other races, cultures, and lifestyles without being judgmental or imposing your own personal beliefs and feelings on them? Yes No Shoals CASA works in both Colbert and Lauderdale County Courts. Do you have a preference in which Court you would be assigned to work on behalf of children? Yes No Reference Information: CASA is required to obtain reference information for all CASA Volunteer applicants. PLEASE LIST THREE REFERENCES: (Two personal and one professional persons not related to you who have known you for at least three years.) Please include full mailing address, including zip code. 1. Name: Address: City, State, ZIP: Phone no: Relationship: 4
2. Name: Address: City, State, ZIP: Phone no: Relationship: 3. Name: Address: City, State, ZIP: Phone no: Relationship: Legal Information: A. Have you ever been convicted of any of the following crimes? Murder Yes No Kidnapping Yes No Rape in the 1 st Degree Yes No Arson in the 1 st Degree Yes No Any Crime dealing with abuse of children, including but not limited to: Incest Yes No Sodomy Yes No Sexual Misconduct Yes No Sexual Exposure Yes No Enticing a Child Yes No Other Yes No B. Have you ever been convicted of any offenses by a civilian or military court? (exclude minor traffic violations) Yes No C. Are you now under charges for any offense? Yes No 5
D. If you answered yes to any of the above, provide details on the chart below or on a separate sheet of paper. State the date and place of arrest. Give the nature of the offense and current status or disposition including sentence or fine imposed. Provide a complete explanation of the circumstances. If you wish, place the separate sheet in a sealed envelope and attach it to this application. The information provided in this section will be verified in the event you are accepted as a CASA Volunteer. Only a limited number of CASA employees will have access to this information. Consequently, any missing or inaccurate facts may be grounds for termination of application or service in the CASA program. Falsifying information on this Volunteer Application will be grounds for termination from the CASA program. CASA will reject any applicant found to have been convicted of, or having charges pending for, a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children or the program's credibility DATE CHARGE PLACE ACTION TAKEN You are required to notify the CASA Program Director IMMEDIATELY in the event that criminal charges are brought against you. In connection with any application for Volunteer work with CASA the applicant shall read and accept the following Declaration. By my signature below, I declare that I understand that I have completed an application for a CASA Volunteer position only and having submitted same does not imply any promises of acceptance on behalf of the CASA program. I have read this Volunteer Application and, to the best of my ability, I have provided complete and accurate information. I understand that the falsifying of information on this application may result in immediate termination from the CASA Program. I further understand that I must submit to an extensive background screening process if I am selected as a potential candidate for a Volunteer position with CASA, and that I must execute a release of information in connection with the background screening. My failure to execute such a release will immediately result in the withdrawal of my Volunteer Application. If the screen reflects that I am found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children of the CASA program or to the CASA program itself, that I will be rejected as a CASA Volunteer candidate. I understand that I am required to immediately notify CASA of any criminal charges that are filed against me, whether in the past, present or future, and that any alleged criminal charges may be grounds for dismissal from the CASA program. Signature of CASA Volunteer Applicant Date of Application 6
This completed application should be returned to the CASA office, along with an Authorization for Background Screening (EISi Authorization), in order that an interview may be scheduled with the CASA Volunteer Applicant. Refusal to execute authorization for background screening will result in an automatic dismissal of a Volunteer s application. You may return the information via mail or in person to the CASA office at the address listed below. Shoals CASA 102 Jackson Court Sheffield, AL 35660 Our staff is here to help answer any questions you may have about the CASA program and the Volunteer Application process. You may speak with either our Executive Director: Andrea Holt or our Volunteer Coordinator: Rachel Aday by calling our office with any questions. (256) 765-0041 Office 7
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