Volunteer Application (1010) "*" indicates required fields Step 1 of 9 11% CASA of the Heartland 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 SSNAKAHome 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 CountyGenderSelect one...FemaleMaleOther/DeclineHispanic Yes No 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 Mobile Phone*Home PhoneWork PhonePreferred Phone Number*Please selectHome PhoneWork PhoneMobile PhonePrimary LanguageOther Languages EducationTypeDegreeMajorContact InformationPlease provide at least one (1) Emergency Contact.Emergency ContactsName*Relationship*Phone*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 any personal and/or professional experience you have with community and volunteer organizations.*Employment HistoryPlease tell us about your current or most recent work experience.Career TypeStatusPlease selectFull TimePart TimeStudentUnemployedRetiredOtherI decline to respondCurrent Employer Yes Work HoursFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Job TitleReason for LeavingCompanyAddressResponsibilitiesSupervisor's NamePhone NumberPermission to contact Yes No Vehicle InformationPlease tell us about your ability to travel to and from CASA of the Heartland and court events.Do you have access to a vehicle?* Yes No Driver's License Number*State*Expiration Date* MM slash DD slash YYYY Auto Insurance CompanyExpiration Date* MM slash DD slash YYYY Vehicle Related QuestionsHas your driver's license ever been revoked or suspended?* Yes No If yes, please explain*Has your auto insurance ever been revoked, or have you ever been denied auto insurance?* Yes No If yes, please explain* BackgroundPlease answer the following questions. If you answer YES, please provide a brief description.Have you lived at your current address for less than five (5) years?* Yes No If yes, please list all previous addresses including city, state and ZIP code*Do you have a connection in any way to the US armed services?* Yes No If yes, please explain*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 of, pleaded guilty to or pleaded no contest to a crime?* Yes No If yes, explain (include date, county, and state)*Are you, or have you ever been a sex offender registered with any Federal, State, or Local government agency, including listing on a public website?* Yes No If yes, please explain*Can you think of any reason why a judge may be reluctant for you to serve as a CASA volunteer?* Yes No If yes, please explain* Personal ReferencesSomeone other than relatives and at least one reference from someone other than a friend or co-worker, for an example: teacher, civic organization(s) contact that you are a member of, or employerReference 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.Are you willing to commit to eighteen (18) months of volunteer service?* Yes No I certified that I have read this application and the information on it is complete and correct. I understand that any omissions or misrepresentations of information is ground for termination of my volunteer activity.* Yes No I understand that CASA of the Heartland reserves the right to publish any press release, photo, and/or names pertaining to CASA events.* Yes No I understand that CASA of the Heartland reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All information obtained will be held in the strictest confidence.* Yes No I consent to a routine check of criminal records, as a standard part of applying to CASA of the Heartland.* 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 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 willexamine 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. 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 & DateUntitled