Volunteer Application (1304)

CASA of the Appalachian Mountains Volunteer Application

Thank you for your interest in becoming a volunteer and taking time to complete our application. This application can only be submitted electronically. Be sure to press the "SUBMIT" button at the end. You will be asked for 3 references, including email addresses. This application takes approximately 30 minutes to complete. Thank you again.

CAPTCHA

Personal Information

Name*

First Middle Last

Maiden Name

Home Address*

Street Address Address Line 2 City State ZIP

Email*

Enter Email Confirm Email

Phone

Are you employed now?

Yes

No

May we contact your present employer?

Yes

No

Referred By

How did you hear about this position?

Emergency Contact

First Name

Last Name

Relationship

Phone

Email

Address

City

State

ZIP

Education

Type

Degree

Major

Employment History

From Date

To Date

Company

Address

Street Address Address Line 2 City State ZIP

Job Title

Responsibilities

Reason for Leaving

Additional Personal Information

Are you a U. S. citizen or approved to work in the United States? (Birth certificate, Driver’s License, Visa, Etc.)

Yes

No

What document can you provide as proof of citizenship or legal status?

Have you ever been convicted of a criminal offense (felony or misdemeanor)? If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

Please list below the skills and qualifications you possess for the position for which you are applying:

What type of licenses or certifications do you hold that would assist in your performance on this job?

What is your experience in child welfare, foster care, adoption, and/or child advocacy? Please explain your successes.

Do you have experience working with children? If yes, please describe the capacity of such role:

Why are you interested in being a CASA Volunteer?

Personal References

Please provide the following information for three, character references not related to you:

Reference 1 Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Email*

Enter Email Confirm Email

Reference 2 Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Email*

Enter Email Confirm Email

Reference 3 Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Relationship*

Email*

Enter Email Confirm Email

BACKGROUND CHECKS REQUIREMENT: My signature below authorizes the Kentucky CASA Network and/or CASA of the Appalachian Mountains to make necessary background checks to determine suitability of to serve as a child advocate. This may include but is not limited to child abuse and neglect records, criminal records, sex offender registries and any other individuals or agencies that may have knowledge of applicant. These checks will be conducted prior to acceptance to the CASA program and periodically for the duration of your affiliation with the program.”

LIST OF PREVIOUS RESIDENCES: Please list ALL complete addresses of residence during the last seven years.

AT-WILL The relationship between you and the CASA of the Appalachian Mountains is referred to as “at will.” This means that your services can be terminated “at will” for any reason, with or without cause, with or without notice, by you or the CASA of the Appalachian Mountains. No representative of the CASA of the Appalachian Mountains has authority to enter into any agreement contrary to the foregoing “at will” relationship. You understand that your role as a volunteer is “at-will” and that you acknowledge that no oral or written statements or representations regarding your position as a volunteer can alter your at- will status, except for a written statement signed by you and our CASA OF THE APPALACHIAN MOUNTAINS Executive Director.

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE. AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND IF I BECOME A VOLUNTEER FOR CASA OF THE APPALACHIAN MOUNTAINS THAT MY ROLE AS A VOLUNTEER REPRESENTATIVE MAY BE TERMINATED AT ANY TIME.

Name & Date

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