Volunteer Application (0173) "*" indicates required fields Step 1 of 8 12% CASA by the Lakes Volunteer ApplicationThank 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 InformationName* First Middle Last Maiden NameHome 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 How long at this address?Date of Birth* MM slash DD slash YYYY Mobile Phone*Home PhoneWork PhonePreferred Phone Number*Please selectHome PhoneWork PhoneMobile PhoneHome Email* Enter Email Confirm Email Preferred Gender*Select one...FemaleMaleRaceSelect one...African AmericanAmerican Indian/Alaska NativeAsianCaucasianMulti-racialOtherUnknownEthnicity*Select one...Hispanic/LatinoNot Hispanic or LatinoUnknownSSN*Driver's License #*State of Issue*Are you employed?* Yes No If yes, by whom?*May you be called at work?* Yes No Occupation*Marital Status* Divorced Married Separated SIngle Unknown Widowed If married, Spouse Name* First Last Education ExperienceSelect highest level completedHigh School* 9 10 11 12 College 1 2 3 4 Graduate/ Professional 1 2 3 4 If College, what institution(s):Degree*Major* Work ExperiencePlease also include any experience working with children.1. EmployerResponsibilitiesDates of Service2. EmployerResponsibilitiesDates of Service3. EmployerResponsibilitiesDates of Service4. EmployerResponsibilitiesDates of Service5. EmployerResponsibilitiesDates of ServiceDo you have any training or experience in any of the following areas? Child Welfare Teaching Social Work Law Enforcement News Media Psychology Mental Health Counseling Medicine Public Relations Fundraising Child Development Public Speaking Child Care Advertising Graphic Design/Art Writing Drug/Alcohol Abuse Program List any community activities, membership in clubs, religious and/or organizations:Hobbies/Interests:Languages Spoken (other than English): Have you ever applied to volunteer or have you ever served as a volunteer with another CASA/ GAL program before?* Yes No If yes, please list the names of the program in the space below. The CASA program may be contacted.*List previous and current volunteer work and include dates of service:*What strengths and weaknesses do you think you bring to the CASA program?*Have you ever been involved in, or been the subject of, an investigation conducted by the Department for Community Based Services (DCBS)?* ReferencesPlease list three (3) character references that have known you at least a year and are not related to you by blood or marriage. Three references are required for all CASA volunteers.Reference 1 Name* First Last 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 Phone*Relationship*Email* Enter Email Confirm Email Reference 2 Name* First Last 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 Phone*Relationship*Email* Enter Email Confirm Email Reference 3 Name* First Last 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 Phone*Relationship*Email* Enter Email Confirm Email StipulationsAs a CASA volunteer you will be required to attend court hearings for the child(ren) you represent. Will you be able to arrange your schedule to attend these hearings?* Yes No Are you willing to be sworn by the judge to an oath of confidentiality?* Yes No Are you prepared to complete 30 hours of pre-service training?* Yes No Are you willing to commit to one year of CASA volunteer service?* Yes No Have you ever been convicted of a crime other than a traffic violation?* Yes No If Yes, what charge? Date? Where?*Do you consent to a routine check of your criminal records?* Yes No Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer?* Yes No If Yes, what reason?* ReleaseBy submitting this application electronically, I hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize CASA by the Lakes and any law enforcement agency they authorize, to investigate my background to determine my fitness as a potential volunteer. 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 two years 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 with those 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 ability to provide quality services to abused and neglected children, my services as a CASA volunteer will be terminated. 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.Certify* I agree to and accept the terms and conditions above.Name & Date