Volunteer Application (1045) "*" indicates required fields Step 1 of 7 14% CASA Corridor of East Tennessee 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 Applicant InformationName* First Middle Last Home 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 Home PhoneMobile Phone*Work PhonePreferred Phone Number*Please selectHome PhoneWork PhoneMobile PhoneCan you be contacted at work?* Yes No Home Email* Enter Email Confirm Email Work Email Enter Email Confirm Email Best Time to Contact*Date of Birth* MM slash DD slash YYYY Gender*Select one...FemaleMaleRaceSelect one...African AmericanAmerican Indian/Alaska NativeAsianCaucasianMulti-racialOtherUnknownEthnicity*Select one...Hispanic/LatinoNot Hispanic or LatinoUnknownDo you speak any other languages?* Yes No Second Language*Marital Status* Divorced Married Separated SIngle Widowed Spouse's NameEmergency 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*Select one...ParentChildSpouse/PartnerFriendSiblingOtherInclude the Emergency Contact's relationship to you. Employment/Work and Volunteer HistoryEmployment status: Full time Part time Retired Student Volunteer 1. Company/Volunteer ProjectAddress 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 Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Supervisor Name First Last PhoneBrief Description of Work2. Company/Volunteer ProjectAddress 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 Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Supervisor Name First Last PhoneBrief Description of Work3. Company/Volunteer ProjectAddress 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 Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Supervisor Name First Last PhoneBrief Description of Work EducationHigh SchoolHighest Completed 9 10 11 12 CollegeHighest Completed 1 2 3 4 Other Education ExperienceDo you have any training or experience in any of the following? (Please check all that apply) Mental Health Counseling Substance Abuse Programs Social Work Advertising or Public Relations Fundraising Child Development Mediation Computers Graphic Design News Media Writing General InformationHow did you become aware of CASA?Describe your experience working with children:As a CASA volunteer you will be required to attend court hearings for the children you represent. Will you be able to arrange your schedule to attend these hearings? Yes No Are you willing to commit to one year of volunteer services? Yes No What are your reasons for wanting to participate as a CASA volunteer?Have you had any personal experience involving Child Welfare?* Yes No If yes, please explain:*Have you had any personal experience involving Court System?* Yes No If yes, please explain:*Have you had any personal experience involving Foster Care?* Yes No If yes, please explain:*Have you had any personal experience involving Other Child Service Agencies?* Yes No If yes, please explain:*Have you ever been convicted of a crime other than a traffic violation?* Yes No If yes, what charge? Date convicted? Where?*Have you ever been accused of child abuse or neglect?* Yes No If yes, please explain:*Are you or someone in your household currently or have been involved in court proceedings or litigation of any kind?* Yes No If yes, please explain:* ReferencesAs part of your application, please provide at least three references of people who know you well, other than relatives. For example, an employer, a friend, a teacher. Please provide contact information below.Reference 1 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email 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 Reference 2 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email 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 Reference 3 Name* First Last Phone*Relationship*Email* Enter Email Confirm Email 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 Affirmation and ReleaseI hereby affirm that all of the answers provided on my volunteer application are true. All statements made on this application, including employment information, are subject to verification as a condition of volunteer services. I hereby give my permission for you to verify any information included in this application. I hereby authorize CASA Corridor of East Tennessee (McMinn, Meigs, and Rhea counties) 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, CASA Corridor of East Tennessee, 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 who are directly involved in the case or who will be consulted for their professional knowledge and expertise. Furthermore, pursuant to applicable laws in my state concerning authority to obtain information, I authorize CASA Corridor of East Tennessee to obtain all investigative records for examination for the purpose of verifying the accuracy of criminal violation information contained on this application; and/or supply a fingerprint sample and submit to a criminal history record check to be conducted by any state. I understand that failure to authorize CASA Corridor to complete background checks or provide requested information to complete background checks or if I do not pass background checks, eliminate me from further consideration as a CASA volunteer. I also understand that CASA can reject my application for any reason. CASA Corridor will reject any applicant found to have been convicted of, or having pending charges, a felony or misdemeanor involving a sex offense, child abuse, or neglect, or related acts that would pose risks to children or this agency’s program.Certify* I agree to and accept the terms and conditions above.Name & Date