Volunteer Application (0732)

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Step 1 of 13

CASA/GAL Volunteer Application

CASA trainees are required to attend all pre-service training classes. You may find the next training class dates by going to the Lucas County CASA website (www.casakids.net), place your cursor over "Volunteer Resources" and click on the "Pre-Service Training" menu option.

CAPTCHA

Your Information

Are you able to attend all of the CASA pre-service training dates?*

Yes

Please contact me regarding this.

Contact Me

Last Name*

First Name*

M.I.

Nickname

Date of Birth*

MM slash DD slash YYYY

Your pronouns

He/His

She/Her

They/Them

Other

Other, please specify

Have you been known by any other names or aliases?*

Yes

What other names?

Home Phone*

Mobile Phone*

Email*

Enter Email Confirm Email

Race/Ethnicity*

Alaska Native

African American

Asian

Caucasian

Latino

Multi-Racial

Native American

Other

Lucas County CASA actively seeks diverse volunteers from all walks of life.

Current Address:

Current*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

From (Mo./Year) to Present*

Prior Address 1:

List your address(es) for the last seven (7) years in the field groups below.

Prior Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From (Mo./Year)

To (Mo./Year)

Prior Address 2:

Prior Address 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From (Mo./Year)

To (Mo./Year)

Prior Address 3:

Prior Address 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From (Mo./Year)

To (Mo./Year)

If more than three prior addresses (in the last 7 years), please list below. Include From/To dates:

Employment

Employment Status*

Full Time

Part Time

Not Employed

Retired

Seeking Employment

Student

Name of Employer*

Job Title*

Briefly describe your work*

May we call you at work?*

Yes

Work Phone

Work Email

Enter Email Confirm Email

How long have you held this job? (Years/Months)

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relationship*

Emergency Contact City/ST*

Education

Highest Education Level*

GED

High School Grad

Some College

2-Yr. Degree

4-Yr. Degree

Post-Grad

Major Field of Study

Minor Field of Study

Experience/Skill

Describe your professional or volunteer experience with children

Do you currently volunteer in any capacity?*

Yes

If yes, indicate position and hours per week:*

List any foreign language(s) or sign language skills:

Have you applied to or volunteered for another CASA program in Ohio, another state, or a U.S. Territory?*

Yes

If yes,indicate which programs (provide all):

History

A criminal history may or may not prevent an applicant from being accepted. Acceptance as a CASA/GAL volunteer is determined on a case by case basis. Lucas County CASA reserves the sole right to determine which individuals are suitable to become CASA volunteers. If in doubt, please call us to discuss your criminal record.

Have you ever been contacted by a child protective service agency?*

Yes

County/State

Are you currently or have you been a foster care provider?*

Yes

County/State

Do you have any history with a Juvenile Court system?*

Yes

County/State

Do you have any history with agencies offering services to children?*

Yes

Name of Agency

If you checked 'Yes' to any of above, please explain circumstances and year(s)*

Criminal History

Have you ever been charged or convicted of a crime or serious traffic offense (including OVI or DUI)?*

Yes

If you checked 'Yes,' list charges/convictions & date(s)*

Have you ever had a charge redacted or expunged from your criminal record?*

Yes

If yes, explain here*

Have you been involved in a domestic violence incident within the past two years?*

Yes

Please note that applicants cannot have been involved in a domestic violence incident within the past two years to be accepted as a CASA volunteer.

Have you been a party to any type of protection order or no-contact order?*

Yes

If yes, list each order, date of order, length of time of order, and circumstances below*

Personal

All CASA volunteers must hold a valid driver's license and current automobile insurance (liability). For those with no driver's license due to a medical disability, please call us. Volunteers will be required to provide the CASA Office with a current driver's license and proof of current liability insurance.

Do you have a valid driver's license?*

Yes

Do you have valid auto insurance (liability)?*

Yes

Do you have access to a car?*

Yes

Do you agree NOT to transport CASA children or their family members under any circumstances?*

Yes

Do you have any health problems or disabilities?*

Yes

If yes, please list:*

Have you ever received or been recommended by a professional for drug and/or alcohol treatment or counseling?*

Yes

Have you ever received, or been recommended by a professional for treatment or counseling for mental health, psychological or psychiatric concerns?*

Yes

Are you currently in mental health or substance use disorder therapy?*

Yes

If yes, name of therapist, doctor, or agency:*

How Heard

How did you learn about CASA (Court Appointed Special Advocates)?*

Billboard

Facebook

CASA Volunteer

Google Search

Friend/Relative

Ohio CASA Association

National CASA Association

Newspaper

Public Library

Radio

Speaker

Television

Other

[Check all that apply.]

CASA Volunteer Name*

I hereby give my informed consent to the Lucas County Juvenile Court (LCJC) Court Appointed Special Advocate/ Guardian ad Litem (CASA/GAL) program to complete a thorough investigation of my character and fitness to be a CASA/ GALVolunteer. I understand that by signing this release, I authorize inquiries to be made concerning my suitability as a volunteer to references that I have provided, which may include my past and present employers. I further authorize FBI, national, state, and/or local police record checks, Bureau of Criminal Investigation checks, sexual offender registry checks, mental health inquiries, and child protective services agencies history checks. Child protective services agencies will be asked for information about any time my name appears in their records as an alleged perpetrator of child abuse or neglect. Also,child protective services agencies will be asked to share any additional relevant information where my name appears in their records. I understand that information requested in this application and other information that may otherwise be obtained will be used only to decide my fitness and suitability to serve as a CASA/GAL Volunteer and may be shared with other departments of the Lucas County Juvenile Court and other CASA programs, if appropriate. I further consent to additional, future background checks on me to remain a CASA/GAL Volunteer. I here by agree to cooperate with such required checks and/or investigations and to sign all necessary releases or resign as a CASA/GAL Volunteer.

This release is good until revoked by me, in writing, at any time before it has been acted upon.

Criteria used in the selection of CASA/GAL Volunteers will be to ensure that each accepted applicant can meet the responsibilities of a CASA/GAL Volunteer and will not pose a risk to children or the program's credibility. No individual will be rejected because of race, color, religious creed, sexual orientation, national origin, sex, handicap, age (if at least 21), or marital status. I understand that the LCJCCASA/GAL program reserves the sole right to determine which individuals are suitable to become CASA/GAL Volunteers.

Applicants who refuse to sign this release, who omit important information, or who fail to complete this application accurately and honestly will not be considered for the Lucas County CASA/GAL program.

Applicant's Typed *SIGNATURE

Date of Birth*

MM slash DD slash YYYY

Consent*

*By typing my name above and checking this box, I attest that I am the Applicant and Preparer of this document and all information contained herein is accurate, honest, and complete.

Full Legal Name

Date

MM slash DD slash YYYY

Social Security Number

(If you would rather not submit your Social Security Number here, please call the CASA Office at 419-213-6753 to give us your number by phone).

Release of Information

Also required is a hand-written signature of the Lucas County CASA/GAL Release of Information form for certain background checks that will not accept an electronic signature. Please download the Lucas County CASA/GAL Release of Information form here. Then print it, sign it, scan it, and send it to casaforms@co.lucas.oh.us. If you have any questions please contact us at (419) 213-6753.