CASA of South Texas

CASA of South Texas P.O. Box 343, Pleasanton, Texas 78064 830-569-4696 Phone/830-569-4697 Fax VOLUNTEER APPLICATION

Name: ______Date of Birth: ______

Address:______

______E-mail: ______

Telephone: (H): ______(W): ______(Cell): ______

Birthplace: ______Ethnicity: ______Religion: ______

Social Security #: ______Level of Education: ______

Student?: ______Which school?______Full time/Part time?: ______

Degree or Major: ______Graduation Date: ______

Employer: ______Full time/Part time?: ______

Employment Address: ______

Position: ______Supervisor: ______

Bilingual?: ______Fluent in which language?: ______

Driver’s license #: ______State: ______Do you have transportation?: ______

IN CASE OF EMERGENCY, PLEASE NOTIFY: ______

Marital Status: □ Single □ Married □ Divorced □ Widowed Spouse’s Name: ______

Where is spouse employed: ______Work Address: ______Work Phone #: ______

Children (List Names and Ages): ______

Do you have experience working with children?: □ Yes □ No If yes, please explain by providing type of activity, length of participation, ages of children, and if on professional or volunteer basis):

______

1 Please tell us about any personal or professional experience with the following: Child Abuse: ______Foster Care: ______Other service agencies:______

Do you, or anyone with whom you reside or regularly come into contact with, have a criminal history or involvement with the courts or CPS? □ Yes □ No If “yes”, who, when and where? ______

Have you ever worked with other children’s organizations? □ Yes □ No Which ones? ______

What were your responsibilities? ______

Present memberships, including offices held, in clubs or local groups: ______

Please list other volunteer experiences: ______

Have you ever applied to this or any other CASA in the past two years? □ Yes □ No If “yes”, when and where? ______

Why do you want to become a CASA volunteer? ______

What particular strengths do you feel you have which will add to your success as a CASA volunteer? ______

What weakness do you feel you have in working as a CASA volunteer? ______

Do you give CASA of South Texas permission to obtain additional information from other sources for screening purposes? □ Yes □ No Are you now receiving or have you ever received counseling of any kind? □ Yes □ No Have you ever been hospitalized for an emotional problem? □ Yes □ No Have you ever been charged and/or convicted of a misdemeanor? □ Yes □ No Have you ever been charged and/or convicted of a felony? □ Yes □ No Have you ever been convicted of a traffic violation? □ Yes □ No Have you had any DWI arrests or convictions? □ Yes □ No Have you ever had your license revoked or suspended? □ Yes □ No Do you now or have you ever had a chemical or alcohol dependency problem? □ Yes □ No Have you ever had treatment for chemical or alcohol dependence? □ Yes □ No If “yes”, tell dates of treatment and length of sobriety: ______Do you have any kind of health condition that may impair your work? □ Yes □ No If “yes”, please explain: ______Have you ever or do you now engage in sexual misconduct, including pornography, that could cause harm to a child, to yourself, or to CASA of South Texas? □ Yes □ No Have you ever been or are you currently on probation and/or parole? □ Yes □ No If “yes”, please explain: ______

2 As a CASA volunteer over 21 years of age, will you: ___ Participate in 30 hours of CASA training at no charge ___ Successfully pass CPS and criminal background checks ___ Attend all hearings and staffings when possible on your case as scheduled ___ Visit with the children monthly in their placements ___ Participate in fact finding, monitoring and reporting representing children’s best interests ___ Interview a variety of sources ____ Perform and document minimum monthly requirements regarding the child(ren) you represent ____ Submit monthly stat cards in a timely manner ___ Attend 12 hours of annual CASA continuing education ___ Maintain confidentiality at all times ___ Honor the 3 I’s: “Independence, Integrity, Impartiality” ___ Communicate effectively and appropriately ___ Deal maturely with emotional situations ___ Demonstrate sensitivity to cultural differences ___ Secure current liability insurance on your car

Provide the name of automobile liability insurance carrier and policy number: ______Please attach a copy of your current insurance card and valid driver’s license with this application.

Please list three (3) personal or professional references (no family members), including name, occupation, address and phone number:

1. ______2. ______3. ______

THE UNDERSIGNED ACKNOWLEDGES AND AGREES THAT: 1. He/she is not obligated, if called upon, to accept a case herein applied for, and that 2. CASA of South Texas is not obligated to assign him/her to a case, and that 3. As a part of CASA’s policy, additional personal information will be gathered during the interview process, and that 4. CASA of South Texas retains the right to refuse any individual it feels would not be appropriate for the program and, further, that CASA is not required to state the reason(s) for non-acceptance, and that 5. The volunteer’s file is held in strictest confidence and is solely the property of CASA of South Texas.

I give my permission to CASA of South Texas to release information about my experience as a CASA volunteer to any other CASA program to which I may apply in the future.

I have truthfully responded to all of the questions on this application.

“I am interested in becoming a CASA volunteer and know no reason why I should not be assigned to a child the program is court-ordered to serve. I am aware that the children in the CASA program have been abused, neglected or abandoned by adults, and since I do not want to be another cause of disappointment to the children, I agree to a minimum commitment of one year to the case to which I am assigned.”

______Applicant’s Signature Date

It is the policy of CASA of South Texas to implement affirmatively equal service to all clients without regard to race, religion, sexual orientation, age, gender or national origin. Any applicant found to have been convicted of, or have charges pending for a felony or misdemeanor involving, a sex offense, child abuse or neglect, a violent act, or related acts that would pose risks to children or CASA of South Texas’ credibility, will not be accepted into the program. Refusal to sign a release of information or submit to any required background checks will result in immediate rejection of your application.

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CASA of South Texas P.O. Box 343 Pleasanton, Texas 78064