Volunteer - Coweta CASA

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Social Security number

Home phone number

Work phone number

Cell phone number

Email

Emergency phone

Emergency contact

Place of Employment

Length of Employment

Position

Fax number

GenderFemaleMale

Date of birth

Do you speak another/secondary Language?FrenchSigningSpanishOther

Have you ever worked for the Juvenile Court?YesNo

Have 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?YesNo

If yes, please explain:

Have you ever been convicted of any violation of law other than minor traffic violation?YesNo

If yes, please explain:

Do you consent to a routine check of your criminal records?YesNo

Can 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:

Name

Phone

Name

Phone

Name

Phone

Name

Phone

This 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 Signature

Date