Volunteer Application (0467) "*" indicates required fields Step 1 of 9 11% CASA of Midwest Kentucky, Inc. 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 QualificationsAre you at least 21 years old?* Yes No Personal InformationName* First Middle Last AKAHome 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 CountyMarital StatusPlease selectDivorcedMarriedSingleWidowedGenderSelect one...FemaleMaleOther/DeclineEthnicity Hispanic/Latino Not Hispanic/Latino RaceSelect one...African AmericanAmerican Indian/Alaska NativeAsianCaucasianMulti-racialOtherUnknownDate 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 selectHome PhoneWork PhoneMobile PhonePrimary Language EducationTypeDegreeMajorContact InformationPlease tell us about the people who live with you.Spouse/PartnerFirst NameMiddle NameLast NamePhone NumberCompany NamePosition/TitleChildrenFirst NameLast NameAgeGenderSelect one...FemaleMaleOther/DeclineEmergency ContactsFirst NameLast NameRelationshipPhone 1Phone 2ExperiencePlease 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 any personal and/or professional experience you have with community and volunteer organizations.Organization NameSupervisor First NameSupervisor Last NameFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY ResponsibilitiesReason For LeavingEmploymentPlease tell us about your work history.Employment HistoryCareer TypeStatusPlease selectFull TimePart TimeStudentUnemployedRetiredOtherI decline to respondCurrent EmployerJob TitleCompanyAddress 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 ResponsibilitiesWork HoursFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Reason for LeavingSupervisor First NameSupervisor Last NamePermission to contact Yes No Phone Number Vehicle InformationPlease tell us about your ability to travel to and from CASA and court events.Driver's License Number*State*Expiration Date* MM slash DD slash YYYY Auto Insurance CompanyExpiration Date MM slash DD slash YYYY BackgroundPlease answer the following questions.What do you feel are the strengths and weaknesses that you bring to this program?*What are your reasons for wanting to participate as a CASA volunteer?*Briefly explain what led to your decision to apply for a position in the CASA program? (What attracted you to this particular program?)*Briefly explain your philosophy of parenting, including the rights and responsibilities of both parents and children.*Briefly explain what role you believe society should play in: a) Protecting the rights of children. b) Helping a family overcome hardships and remain living together as one unit.*Please write a five paragraph autobiography.*Are there best times (morning, evening, afternoon) and days (weekday, weekend, etc.) to complete 30 hours of initial training for you?*Please explain any experience you have had with children (your own, through work, church, volunteering, etc).*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 arrested? If yes, on what charge?* Yes No If yes, Explanation* Personal ReferencesPersonal References: (Do not list relatives. At least one reference must be from someone other than a friend or co-worker. For example: teacher, therapist, pastor, or employer, if they know you well.)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 AgreementPlease answer the following questions.Does your schedule permit you to attend meetings, court hearings or Interested Party Reviews reviews during the work day?* Yes No Are you prepared to complete 30 hours of pre-service training; and a minimum of 12 hours per year of in-service training?* Yes No Are you willing to commit to at least 18 months of volunteer services?* Yes No Do you consent to a routine checks (at least every 2 years while active as a CASA Volunteer): Social Security number verification, criminal records from the court jurisdiction in which the applicant currently resides and works, State criminal records, FBI or other national criminal databases, Dru Sjodin National Sex Offender Registry, State Sex offender Registry, Child abuse registry or child protective services check where permissible by law and the KY Adult Caregiver Misconduct Registry.* Yes No By submitting this application electronically, I hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize CASA of Midwest Kentucky, Inc. and any agency they authorize, to investigate my background to determine my fitness as a potential volunteer. The following background checks are required per National CASA Standards: i. Social security number verification. ii. Criminal records from the court jurisdiction in which the applicant currently resides and works. (including last 7 years where lived or worked) iii. State criminal records (last 7 years where lived/worked) iv. FBI or other national criminal database v. Dru Sjodin National sex of ender registry. vi. Child abuse registry or child protective services check where permissible by law. vii. All State sex of ender websites from last 7 years where the applicant has lived or worked. By submitting this application you agree for the above mention checks to be completed. Additional forms may be required to complete checks along with a copy of your current driver's license. 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 CASA of Midwest Kentucky, Inc. with as much advance notice as possible. 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 agree to and accept the terms and conditions above.Name & Date