Volunteer Application (237) "*" indicates required fields Step 1 of 10 10% Tri-Lakes CASA, Inc. Volunteer ApplicationQualifications and Personal Information 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 have the ability to print a copy of the application for your records. You will be asked for 3 references, including email addresses. The application cannot be saved so you need to complete it in one sitting. This application takes approximately 30 minutes to complete. Thank you again.CAPTCHA QualificationsAre you at least 21 years old?* Yes No Are you comfortable using basic computer skills including Internet access, word processing and email?* Yes No Would you consider yourself to be good with deadlines, organization, and writing that is short and to the point?* Yes No Personal InformationName* First Middle Last AKACurrent Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP County*ClarkGarlandGrantHot SpringPikeOtherDate of Birth* MM slash DD slash YYYY Home Email* Enter Email Confirm Email Work Email Enter Email Confirm Email Home PhoneMobile Phone*Work PhonePreferred Phone Number*Please selectHomeMobileWorkLanguagePrimary Language*EducationEducation* GED Some High School High School Some College College Post College Degree*Major*Emergency ContactPlease provide an emergency contact.Emergency Contact Name*Include the phone number of someone we can contact on your behalf in case of an emergency. This should NOT be your own phone number.Phone Number*Relationship* ExperiencePlease tell us about any personal and/or professional experience you have with the following agencies, organizations or areas. You are not required or expected to have any experience in these areas to be a volunteer.Child Protective Agencies* Yes No If yes, please explain:*Foster Care* Yes No If yes, please explain:*Juvenile Court* Yes No If yes, please explain:*Other Child Service Agencies* Yes No If yes, please explain:*Child Abuse or Neglect* Yes No If yes, please explain:*Domestic Violence* Yes No If yes, please explain:*Mental Illness/Mental Health Treatment* Yes No If yes, please explain:*How did you hear about our program?* Volunteer ExperiencePlease tell us about your involvement, past or current, with any community organizations and/or volunteer experiences.Organization 1 NameSupervisor Name First Last From MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesReason for LeavingOrganization 2 NameSupervisor Name First Last From MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesReason for LeavingOrganization 3 NameSupervisor Name First Last From MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesReason for Leaving EmploymentPlease list your employment history, beginning with your current employment.Career TypeStatus Full Time Part Time Retired Stay at Home Disabled Student Unemployed or Seeking Employment Current Employer Yes No Job TitleCompanySupervisor NamePhone NumberPrior EmploymentStatus Full Time Part Time Retired Stay at Home Disabled Student Unemployed or Seeking Employment Job TitleCompanySupervisor NamePhone NumberPrior EmploymentStatus Full Time Part Time Retired Stay at Home Disabled Student Unemployed or Seeking Employment Job TitleCompanySupervisor NamePhone Number Vehicle InformationThe following information is not needed for our CASA program, although you may need to fill in one or two boxes in order to move on.Driver's License NumberStateExp. DateAuto Insurance CompanyExp. Date Background InformationHave you applied to be a CASA volunteer in another county or state? Have you served in the past as a CASA volunteer in another county or state? If yes, please provide the name of all organizations and dates served.*Do you feel you have any particular strengths that you bring to the program? If yes, please describe.*Do you have any hobbies and/or special interests that you feel are applicable to your work as a CASA volunteer? If yes, please describe.*Please provide a brief statement explaining why you chose to become a volunteer as a Court Appointed Special Advocate.*Criminal HistoryAn applicant having a charge or convictions for a crime involving a sex offense or child abuse or neglect is disqualified as a volunteer. Applicants with other misdemeanor or felony charges or convictions that would not pose a risk to children or negatively impact the credibility of the Program will be considered on a case by case basis considering the time passed since the incident and the level of rehabilitation. Please answer the following questions. If YES, please explain.Have you ever been convicted, charged and or arrested for a crime against a child? If so, please explain.Have you ever been convicted, charged, and/or arrested for any type of sex crime? If yes, please explain.Have you ever been convicted, charged, and/or arrested for any type of violent felony? If yes, please explain.Have you ever been convicted, charged, and/or arrested for any other crimes not previously listed including misdemeanors? If yes, please explain.Are you now or have you ever been to sibling, parent, household member, significant other or spouse of a child who has been the subject of a report to a child protective agency? If yes please explain.Are you now or have you ever been to sibling, parent, household member, significant other or spouse of a child who has been and adjudicated dependent of any juvenile court? If yes, please explainAre you now or have you ever been to sibling, parent, household member, significant other or spouse of a child who has been placed under informal supervision in any county's child's social service agency? If yes please explain. ReferencesPlease provide five (5) references. At least three (3) of those listed must be someone other than a relative.Reference 1 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 2 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 3 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference 4 Name ( Optional ) First Last PhoneRelationshipEmail Enter Email Confirm Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AgreementAre you willing to attend court one day per quarter for the children for whom you are advocating?* Yes No Can you see yourself visiting with a family in their home or with a child in an institution?* Yes No Are you willing to complete 30 hours of pre-service training?* Yes No Are you willing to complete a minimum of 12 hours of continuing education each year?* Yes No Are you able to arrange time off work or adjust your schedule in order to set aside time for appearance in court with advanced notice?* Yes No The initial training for CASA is offered several times throughout the year. Would you be available to begin training soon?* Yes No Are you available for training that happens in the evenings after usual work hours?* Yes No Would you be available for trainings that occur on the weekends?* Yes No Would you be available to accept a case, knowing that the service would be 1 - 2 years?* Yes No ReleaseBy submitting this application electronically, I hereby affirm that all of the answers provided on this volunteer application are true. I hereby authorize the CASA program and any law enforcement agency that CASA authorizes, to verify my social security number and investigate my background to determine my fitness as a potential volunteer advocate. I understand that the information requested in this application will be used only for the purpose of determining my suitability as a CASA volunteer. Further, I understand that completion of training does not guarantee that I will be assigned a case. If I have successfully completed the training and have met all other requirements, and it has been determined that I am a suitable volunteer, I understand that I will be expected to serve a minimum of one year in the CASA program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the program director with as much advance notice as possible. I am aware of the sensitive and confidential nature of the official documents, reports and other material I will examine in my capacity as a CASA volunteer. I will discuss these matters only with those persons directly involved in the case or who will be consulted for their professional knowledge and expertise. I also understand that if for any reason it becomes apparent that my activities are contrary to the policies, goals and/or philosophy of the CASA program, and their desire to provide quality services to abused and neglected children, my services as a CASA volunteer will be terminated.Certify* I submit the statements on this application are true, complete, and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or can result in dismissal at a later time.Name & DateTHANK YOU!We appreciate the time you took completing our application. Following a review, a member of our staff will contact you regarding the next steps. If you have any questions or concerns, please feel free to contact the office. For security, please close your browser.