Volunteer NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweSocial Security numberHome phone numberWork phone numberCell phone numberEmailEmergency phoneEmergency contactEmployment statusFull timePart timeStudentNot employedRetiredPlace of EmploymentLength of EmploymentPositionFax numberGenderFemaleMaleDate of birthEthnicityAfrican-AmericanNative AmericanAsianBi-racialCaucasianAsian-AmericanLatino/HispanicMulti-EthnicOtherFormal Education (Highest year of school completed)Some high schoolGEDHigh schoolSome CollegeCollegePost-graduateDoctorateWhat is your primary Language?EnglishSpanishSigningFrenchOtherDo you speak another/secondary Language?FrenchSigningSpanishOtherReferred byFlierFriendInternetLocal newspaperLocal radioNational mediaNational CASAVolunteer referral agencyOtherHave you ever worked for the Juvenile Court?YesNoHave you ever worked for the Department of Family and Children Services (DFCS)?YesNo(Include service as foster parent)Have you ever had a case with, or investigation performed by DFCS?YesNoIf yes, please explain:Have you ever been convicted of any violation of law other than minor traffic violation?YesNoIf yes, please explain:Do you consent to a routine check of your criminal records?YesNoCan you think of any reason why a judge might be reluctant for you to serve as a CASA Volunteer? If yes, please explain:Why do you want to volunteer for CASA?Please list any volunteer experience and how long:Please list skills and interests:Please list any experience, education or training related to dependent children and families:Please list four references of people who know you well, including only one relative, preferably for whom you have worked in either a paid or volunteer capacity:NamePhoneNamePhoneNamePhoneNamePhoneThis CASA program is hereby authorized to investigate and verify all statements made in this application and to conduct any further investigation it deems necessary to determine my suitability as a CASA volunteer. I understand that application does not assure acceptance in the program. I will be responsible for assuring that my references return the reference request form to the CASA program. I understand that I must sign a release or submit the necessary information required for social security number verification, criminal records check, national sex offender registry and the child abuse registry. If I do not submit the required information, I will not be accepted as a potential CASA volunteer for Coweta CASA. Any potential volunteer 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 CASA program’s credibility will not be accepted as a CASA volunteer.I have carefully considered the job description and training scheduled and, if accepted, will offer my services as a Court Appointed Special Advocate.Applicants SignatureDateRegisterPlease do not fill in this field.