Volunteer Application (1099)

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Cullman County CASA Volunteer Application

Qualifications and Personal Information

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 have the ability to print a copy of the application for your records. You will be asked for 3 references, including email addresses. The application cannot be saved so you need to complete it in one sitting. 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

Address*

Street Address Address Line 2 City State ZIP Code

County

Home Email*

Enter Email Confirm Email

Work Email

Enter Email Confirm Email

Personal Information (continued)

Birthdate*

MM slash DD slash YYYY

Gender*

Race*

Ethnicity*

Marital Status

Home Phone

Mobile Phone

Work Phone

Preferred Phone*

Primary Language*

Education*

Education Type*

Major

Contact Information

Please tell us about the people who live with you.

Spouse/Partner Name

First Middle Last

Phone

Company Name

Position/Title

Child Name 1

First Middle Last

Age

Gender

Child Name 2

First Middle Last

Age

Gender

Emergency Contact

Please provide at least one (1) Emergency Contact.

Name*

First Last

Phone 1*

Phone 2

Relationship*

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 Protection 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

First Last

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Responsibilities

Reason for Leaving

Employment History

Please tell us about your work history.

Career Type

Status

Current Employer

Job Title

Company

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*

State*

Exp. Date*

Auto Insurance Company*

Expiration Date*

Vehicle Related Questions

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.

Do you have any experience working directly with children?*

Yes

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 convicted of any of the following crimes? Murder, Kidnapping, Rape in the 1st Degree, and/or Arson in the 1st Degree? If you answered yes to any of the above, state the date and place of arrest. Give the nature of the offense and current status or disposition including sentence or fine imposed. Provide a complete explanation of the circumstances. Any missing or inaccurate facts may be grounds for termination.*

Yes

If yes, please explain:*

Have you ever been convicted of any of the following crimes dealing with abuse of children, including but not limited to: Incest, Sodomy, Sexual Misconduct, Sexual Exposure, Enticing a Child? If you answered yes to any of the above, state the date and place of arrest. Give the nature of the offense and current status or disposition including sentence or fine imposed. Provide a complete explanation of the circumstances. Any missing or inaccurate facts may be grounds for termination.*

Yes

If yes, please explain:*

Have you ever been convicted of any offense by a civilian or military court (exclude minor traffic violations)?*

Yes

If yes, please explain:*

Are you now under charges for any offense?*

Yes

If yes, please explain:*

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:*

Personal References

PLEASE LIST THREE PERSONAL REFERENCES: (Persons not related to you who have known you for at least three years. Please include full and correct address, and zip code!) At least one reference must be someone other than a friend or co-worker, i.e. minister, teacher, employer, therapist.

Reference 1*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference 2*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference 3*

First Last

Phone*

Relationship*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agreement

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

Yes

Release

Consent*

I agree to the policy below.

By submitting this application electronically, I hereby affirm that all of the answers provided on this 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 will examine 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.

Thank You

We appreciate the time you took completing our application. It has been successfully submitted to the office. Following a review, a member of our staff will contact you regarding the next steps. If you have any questions or concerns, please feel free to contact the office. For security, please close your browser.