<p> Northeast Georgia CASA Volunteer Application</p><p>(Please complete as thoroughly as possible. * Optional)</p><p>PERSONAL:</p><p>Name: ______(First) (Middle) (Last)</p><p>Date of Birth: ______SS #: ______</p><p>Mailing Address: ______</p><p>City: ______State: ______Zip: ______</p><p>911 Address (if different) ______</p><p>______</p><p>Home Phone: ______Cell Phone: ______</p><p>Email Address: ______County: ______</p><p>Emergency Contact Name and Number: ______</p><p>______</p><p>Sex: ______Martial Status* ______</p><p>Ethnic Origin * (Please circle) African American Asian/Pacific Islander Hispanic/Latino Caucasian (Non-Latino) Native American Multi-racial Do Not Wish To Disclose</p><p>Place of Birth: ______Country of Citizenship: ______</p><p>Eye Color: ______Hair Color: ______</p><p>Significant Other’s Name: ______Children and Their Ages:* ______</p><p>______</p><p>Do you or any family members have any experiences related to the Department of Family and Children Services? (If yes, please explain.) </p><p>______</p><p>______</p><p>Have you ever been arrested and/or convicted with any violation of law other than minor traffic violations? (A conviction does not necessarily disqualify you from the CASA program.) Yes ___ No ___ If yes, please explain. ______</p><p>______</p><p>Have you, or any member of your household, been investigated or convicted for any type of sexual misconduct? Yes ___ No ___</p><p>If yes, please explain. ______</p><p>______</p><p>Have you ever sought treatment or are you currently in treatment for a mental health issue or for substance abuse? Yes ___ No ___</p><p>Why do you want to volunteer with the CASA program at this time? </p><p>______</p><p>______EDUCATION:</p><p>Please circle your highest educational level:</p><p>High School Some College BS/BA Masters Doctorate</p><p>If achieved, what is your degree/certification? ______Dates Received: ______</p><p>Do you speak any other languages in addition to English? </p><p>If so, what language(s)? ______</p><p>EMPLOYMENT:</p><p>Current Employment/Employer: ______</p><p>Length of employment: ______Position/Occupation: ______</p><p>If retired, please list last occupation ______</p><p>Year of Retirement: ______</p><p>What is your current employment status? Please circle.</p><p>Full Time Part Time Student Not employed Retired</p><p>Have you ever worked for the Department of Family and Children Services? (This includes being a foster parent.)</p><p>Yes ___ No ___ </p><p>Have you ever worked for the Juvenile Court? Yes ___ No ___ </p><p>Have you lived in Georgia for the past 5 years? Yes ___ No ___</p><p>If no, please list the other state(s) where you resided during the last five years: ______REFERENCES: </p><p>Two (2) Personal References Two (2) Professional References (salaried or non-salaried)</p><p>Name: ______Relationship: ______</p><p>Address: ______</p><p>Phone Number: ______Email: ______</p><p>Name: ______Relationship: ______</p><p>Address: ______</p><p>Phone Number: ______Email: ______</p><p>Name: ______Relationship: ______</p><p>Address: ______</p><p>Phone Number: ______Email: ______</p><p>Name: ______Relationship: ______</p><p>Address: ______</p><p>Phone Number: ______Email: ______</p><p>VOLUNTEER AUTOBIOGRAPHY: </p><p>Please write 1 or 2 pages of your autobiography. Please include:</p><p> Family Background; your growing up years  Your current family situation  Any relevant joys/crisis in your life  Any pivotal situation that brought you to this volunteer opportunity</p><p>Please write and email to Melissa Mitchell ([email protected]) prior to the day of the interview. VOLUNTEER SELF-DESCRIPTION:</p><p>Please circle the one answer below each statement that best describes yourself.</p><p>I work best: 1) Independently 2) With the Support of a Supervisor 3) With the support of a co-worker 4) As part of a larger group</p><p>I thrive on: 1) Consistency 2) Change</p><p>My problem solving thinking is normally more: 1) Strategic 2) Free Flowing</p><p>My current schedule is: 1) Extremely Flexible 2) Somewhat Flexible 2) Flexible – if I am given enough notice</p><p>I feel most comfortable when: 1) I know all the players and possibilities ahead of time 2) I am learning new information</p><p>The way I communicate best is: 1) Verbally 2) In writing</p><p>List eight adjectives other people who know me well would use to describe me: ______</p><p>______</p><p>Northeast Georgia CASA is hereby authorized to investigate and verify all statements made in this application and to conduct any further investigation it deems necessary to determine my suitability as a CASA Volunteer. I understand that it is my responsibility to notify the CASA office immediately if any information in the application changes. I will be responsible for assuring that my references return the reference request for to the program. I understand that the application does not assure acceptance in the program and that it is totally within the CASA program’s discretion to accept or not accept any volunteer applicant. I understand that if I am found to have been convicted of, or having changes pending for a felony or misdemeanor involving a sex offense, child abuse or neglect or related acts that would pose a risk to children or the CASA program’s credibility, that I will not be accepted as a CASA Volunteer. I have carefully considered the job description and training schedule and, if accepted, will offer my services as a Court Appointed Special Advocate.</p><p>Signature: ______Date: ______CONSENT FORM</p><p>I hereby authorize Northeast Georgia CASA to request and receive any criminal history record information pertaining to me which may be in the files of any national, state or local criminal justice agency in the United States. I also agree for Northeast Georgia CASA to request and receive any history record information from the Department of Family and Children Services.</p><p>Name: ______(First) (Middle) (Last) </p><p>Address: ______</p><p>City: ______State: ______Zip:______</p><p>Sex: ___ Race: _____ DOB: ______SS#: ______</p><p>Signature: ______Date: ______</p><p>Notary Public: ______</p>