Volunteer Application (935) "*" indicates required fields Step 1 of 8 12% CASA for Kids, Onalaska, WI 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 CountyMarital StatusPlease selectDivorcedMarriedSingleWidowedGenderSelect one...FemaleMaleOther/DeclineEthnicity Hispanic/Latino Not Hispanic/Latino 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 Home PhoneMobile Phone*Work PhonePreferred Phone Number*Please selectHome PhoneWork PhoneMobile PhonePrimary Language EducationTypeDegreeMajorContact InformationPlease tell us about the people who live with you.Spouse/PartnerFirst NameMiddle NameLast NamePhone NumberCompany NamePosition/TitleChildrenFirst NameLast NameAgeGenderSelect one...FemaleMaleOther/DeclineEmergency ContactsFirst NameLast NameRelationshipPhone 1Phone 2ExperiencePlease 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.Organization NameSupervisor First NameSupervisor Last NameFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY ResponsibilitiesReason For LeavingEmploymentPlease tell us about your work history.Employment HistoryCareer TypeStatusPlease selectFull TimePart TimeStudentUnemployedRetiredOtherI decline to respondCurrent EmployerJob TitleCompanyAddress 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 ResponsibilitiesWork HoursFrom Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Reason for LeavingSupervisor First NameSupervisor Last NamePermission to contact Yes No Phone Number Vehicle InformationPlease tell us about your ability to travel to and from CASA 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 QuestionsCASA volunteers are expected to be able to transport themselves to court hearings, and other CASA events (advanced notice is given.) Will access to reliable transportation pose any difficulties for you? If yes, please explain how you will overcome this obstacle.test Yes No If yes, please explain*Has your driver’s license ever been revoked or suspended? If yes, please explain. Yes No If yes, please explain* Background InformationPlease answer the following questions. If you answer YES, please provide a brief description.Are there other members of your household that you did not list previously? Yes No Please list names, ages, and relationship.*Are you presently attending school? Yes No Please provide the name of school and program.*Please complete the following sentence: "I want to volunteer because ... "Please list any strong interests, knowledge, areas, hobbies, certifications, unique experiences or special skills which you could offer as a volunteer.Have you lived in La Crosse for less than 5 years? Yes No Please list where you have lived the past five (5) years other than La Crosse County*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 for a violation other than a minor traffic offense? (Report all convictions - past and present. Convictions may not automatically disqualify you)* Yes No If yes, please explain*Are you currently involved in a court matter in Wisconsin or any other jurisdiction?* Yes No If yes, please explain*Do you have a close friend or family member currently under any type of court jurisdiction, and/or in any correctional/placement/institution/facility?* Yes No If yes, please explain*Are you now or have you ever been involved with child protection or social services authorities in La Crosse County or any other jurisdiction?* Yes No If yes, please explain* Personal ReferencesPersonal References: (Do not list relatives. At least one reference must be from someone other than a friend or co-worker. For example: teacher, therapist, pastor, or employer, if they know you well.)Reference 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.Will you be able to attend 30+ hours of pre-service training as provided by the CASA program?* Yes No Does your current schedule allow you to attend court hearing, team meetings and CASA events during regular business hours, with advanced notice?* 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 CASA of Midwest Kentucky, Inc. and any agency they authorize, to investigate my background to determine my fitness as a potential volunteer. The following background checks are required per National CASA Standards: i. Social security number verification. ii. Criminal records from the court jurisdiction in which the applicant currently resides and works. (including last 7 years where lived or worked) iii. State criminal records (last 7 years where lived/worked) iv. FBI or other national criminal database v. Dru Sjodin National sex of ender registry. vi. Child abuse registry or child protective services check where permissible by law. vii. All State sex of ender websites from last 7 years where the applicant has lived or worked. By submitting this application you agree for the above mention checks to be completed. Additional forms may be required to complete checks along with a copy of your current driver's license. 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 CASA of Midwest Kentucky, Inc. with as much advance notice as possible. 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. Certify* I agree to and accept the terms and conditions above.Name & Date