Volunteer Application (0471)

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CASA of the Wilderness Trail 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

Home Phone

Mobile Phone*

Work Phone

Email Address*

Enter Email Confirm Email

May we call you at work?*

Yes

Social Security #*

How long have you lived in Kentucky?*

Addresses for the past 7 years

Date of Birth*

MM slash DD slash YYYY

Place of Birth

Marital Status*

Divorced

Married

Separated

SIngle

Unknown

Widowed

If married, Spouse's name*

Spouse's occupation*

Child 1 Name

Date of Birth

MM slash DD slash YYYY

Gender

Child 2 Name

Date of Birth

MM slash DD slash YYYY

Gender

Child 3 Name

Date of Birth

MM slash DD slash YYYY

Gender

Other Member 1 Name

Relationship

Other Member 2 Name

Relationship

Do you drive?*

Yes

Driver's License #

Driver's License Expiration Date

Name of Insurer

Do you have an vehicle available to you?*

Yes

Education

Select highest level completed

High School*

College

Graduate/ Professional

Major*

Degree*

Are you presently enrolled in school?*

Yes

If yes, name of school and course of study*

Demographic Information

All questions in this section are optional and are used to track information relating to diversity and inclusion of volunteers for the program. Applicant will not be subjected to any adverse treatment from the information provided or information not being provided.

Race

Gender

Sexuality

Work Experience

Please also include any experience working with children.

1. Name and Address of present or last employer or volunteer project

Time

Full Time

Part Time

Dates of Service

Supervisor's Name

Brief Description of Work

2. Name and Address of present or last employer or volunteer project

Time

Full Time

Part Time

Dates of Service

Supervisor's Name

Brief Description of Work

3. Name and Address of present or last employer or volunteer project

Time

Full Time

Part Time

Dates of Service

Supervisor's Name

Brief Description of Work

List any other current community activities

Languages Spoken

Hobbies/Interests:

When would you be available for volunteer service?*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Select times*

Morning

Afternoon

Evening

Approximate time you can contribute weekly as a CASA volunteer?*

Are you aware that you will be required to complete initial training?*

Yes

Will you be willing to participate in ongoing training and court appearances?*

Yes

Can you see yourself visiting with a family in their home or with an institutionalized child?

Yes

What do you feel are the strengths you bring to this program?*

Do you have any training or experience in any of the following areas?

Medicine

Criminology

Counseling

Law Enforcement

Psychology

Advertising, PR, or News Media

Drug or Alcohol Programs

Mental Health

Working with children

Public Speaking

Child Welfare

Art or Graphics

Social Work

Child Development

If you selected any above, please describe

Have you ever been arrested for a crime?*

Yes

If yes, what charge?*

Date of Arrest*

Where?*

Can you think of any reason why Judge Shepherd, Judge Walson, or Judge Leach might be reluctant to appoint you to a case?*

Yes

If yes, Why?*

Anyone found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children or the CASA program’s credibility will be rejected. Applicants with other felonies or misdemeanors will be evaluated with regard to the nature of the offense and its impact on the program’s credibility.

How did you learn about the CASA Program?*

Personal References

References must be unrelated to you by blood or marriage. If employed, one reference from employer

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

Emergency Contact

Emergency Contact Name

Phone

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 the Wilderness Trail 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 suitability as a CASA volunteer. Further, I understand that after the successful completion of my training, 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 Executive 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 people directly involved in the case or professionals consulted for their knowledge and expertise.

Certify*

I agree to and accept the terms and conditions above.

Name & Date