Volunteer Application (1009)

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CASA of the Northern Bluegrass Region 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 5 references, including email addresses. This application takes approximately 30 minutes to complete. Thank you again.

CAPTCHA

Qualifications

Are you at least 21 years old?*

Yes

Personal Information

Name*

First Middle Last

SSN*

AKA

Home Address*

Street Address Address Line 2 City State ZIP

County*

Gender*

Race

ethnicity*

Date of Birth*

MM slash DD slash YYYY

Birth City*

Birth State*

Home Email*

Enter Email Confirm Email

Work Email*

Enter Email Confirm Email

Mobile Phone*

Home Phone

Work Phone

Preferred Phone Number*

Marital Status*

Divorced

Married

Separated

SIngle

Unknown

Widowed

Primary Language*

Education*

GED

Some High School

High School

Some College

College

Post College

Degree*

Major*

Contact Information

Please tell us about the people who live with you.

Spouse/Partner

First Middle Last

Spouse Phone*

Company

Position/Title

Children

First/Last Name, Age, Gender

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.

Emergency Contact Phone Number*

Emergency Contact Relationship*

Include the Emergency Contact's relationship to you.

If other, please specify.*

Experience

Please 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

If yes, please explain:*

Foster Care*

Yes

If yes, please explain:*

Juvenile Court*

Yes

If yes, please explain:*

Other Child Service Agencies*

Yes

If yes, please explain:*

Child Abuse or Neglect*

Yes

If yes, please explain:*

Domestic Violence*

Yes

If yes, please explain:*

Mental Illness/Mental Health Treatment*

Yes

If yes, please explain:*

How did you hear about our program?*

Volunteer Experience

Please tell us about any personal and/or professional experience you have with community and volunteer organizations.

Organization Name

Supervisor Name

First Last

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Responsibilities

Reason for Leaving

Employment

Please tell us about your work history.

What is your employment status?*

Full time

Part time

Student

Unemployed

Retired

Other (specify below)

I decline to respond

Career Type

Current Employer

Company

Job Title

Address

Street Address Address Line 2 City State ZIP Code

Responsibilities

Work Hours

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Reason for Leaving

Supervisor Name

First Last

Permission to contact

Yes

Phone

Vehicle Information

Please tell us about your ability to travel to and from CASA and court events.

Do you have access to a vehicle?*

Yes

Driver's License Number

Driver's License State

Driver's License Exp. Date

Auto Insurance Company

Auto Insurance Exp. Date

Vehicle Related Questions

Are there any problems with your securing your own transportation in your work as a CASA Volunteer? If yes, please explain how you will overcome this obstacle. CASA Volunteers cannot bring any non-CASA person with them on any visit, except an attorney or social worker assigned to the case. CASA persons include staff or co-volunteers approved by staff. CASA Volunteers are NOT allowed to transport children and/or children’s family members.*

Yes

If yes, please explain:*

Has your driver's license ever been revoked or suspended?*

Yes

If yes, please explain:*

Background Information

Please answer the following questions. If you answer YES, please provide a brief description.

Have you ever lived outside of Kentucky?*

Yes

If yes, please list each state:*

Have you lived at your current residence for less than seven (7) years?*

Yes

If yes, please provide all past addresses for the past seven years. Please include street address, city/state/ZIP Code and the number of years that you reside there:*

Do you feel you have strengths that you bring to the program?*

Yes

If yes, please explain:*

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

Yes

Medicine Education Mental Health Criminology Counseling Law Enforcement Psychology Advertising or Public Relations Drug or Alcohol Abuse Programs News Media Child Development Writing Child Care Public Speaking Child Welfare Art or Graphics Social Work Fund Raising.

If yes, please explain:*

Criminal History

An 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 for a crime?*

Yes

If yes, please provide the charge(s), date(s) and disposition(s) and location(s) of all arrests:*

Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer?*

Yes

If yes, please explain:*

All background checks will be conducted at least every four years per NCASA Standard 5.B.3.

References

Please list three references of people who know you well, other than relatives. Preferable for whom you have worked in either a paid or volunteer capacity.

Reference 1 Name*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Reference 2 Name*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Reference 3 Name*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Reference 4 Name*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Reference 5 Name*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Agreement

Please answer the following questions.

Are you aware that you will be required to complete pre-service 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

Do you consent to a routine check of your criminal records?*

Yes

Release

By submitting this application electronically, I hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize the CASA of the Northern Bluegrass Region program 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