Court Appointed Special Advocate



Court Appointed Special Advocate

Fifth Judicial District Court

Chaves County New Mexico

This volunteer application form is designed to serve the same purpose as that of an employment application. The CASA Program reserves the right to make any reference checks or inquiries deemed appropriate and necessary to the suitability of any new volunteer (just as reference checks are made on new employees).

We trust that you will understand this in the spirit intended. Any checks or inquiries will be kept in strict confidence. Please be aware that our standards for volunteers are high and not all people who apply will necessarily be accepted. Work with abused and neglected children as a CASA volunteer is extremely rewarding. We are looking forward to talking to you about becoming part of out dedicated corps of volunteers.

PERSONAL INFORMATION (Please Print)

Name:      

Address:      

Telephone #: (H)       (W)       (C)      

E-Mail Address:      

May you be called at work? Yes No Social Security #:      

In what cities have you resided in the last 10 years?      

Date of Birth:       Place of Birth:      

Marital Status:       Previously Married?       Name of Spouse:      

Your Occupation:      

Children Date of Birth Sex

                 

                 

                 

Other members of household:

Name Relationship

           

           

           

Do you drive: Yes No

Do you have an automobile available to you? Yes No

What is the current status of your health?      

YOUR EDUCATION: (Check highest completed)

High School: 9 10 11 12 College: 1 2 3 4

Graduate: 1 2 3 4

Major:      

Degree:      

Are you presently enrolled in school? Yes No

If yes, name of school and course of study:      

WORK / VOLUNTEER HISTORY (Use another sheet if necessary)

1) Name and address of present or last employer or volunteer project:      

Dates:       Supervisor’s Name:      

Brief description of work:      

2) Name and address of next previous employer or volunteer project:      

Dates:       Supervisor’s Name:      

Brief description of work:      

3) Name and address of next previous employer or volunteer project:      

Dates:       Supervisor’s Name:      

Brief description of work:      

List other current community activities and membership in clubs, church, and other organization:      

Languages spoken:      

Hobbies/ Special Interests:      

When would you be available for volunteer service? Check day(s) and times:

MON TUE WED THURS FRI SAT SUN

Morning Afternoon Evening

Approximately how much time can you contribute weekly as a CASA volunteer?

     

Do you have any training or experience in any of the following? (Please mark all that apply.)

Medicine Education Mental Health Criminology

Counseling Law Enforcement Psychology News Media

Advertising or Public Relations Drug or Alcohol Abuse Programs

Child Development Writing Child Care Public Speaking

Child Welfare Art or Graphics Social Work

If you answered yes, please describe:      

Have you ever been arrested for a crime? Yes No

If yes, what charge?      

Date of Arrest/Disp:       Where?      

Have you ever been accused of a crime against a child under the age of 18?

Yes No If yes, please explain:     

How did you learn about the CASA Program?     

PERSONAL REFERENCES: (If you are employed, one reference should be from your employer)

1) Name:      

Address:      

Telephone # :(h)       (c)       (Email)     

Relationship:      

2) Name:      

Address:      

Telephone # :(h)       (c)       (Email)     

Relationship:      

3) Name:      

Address:      

Telephone # :(h)       (c)       (Email)     

Relationship:      

In case of emergency, contact:      

Telephone # :(h)       (w)       (c)     

AFFIRMATION AND RELEASE

I,                , hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize the Chaves County CASA Program to investigate my background to determine my fitness as a potential volunteer. I authorize the CASA program and other appropriate agencies to secure a state and local criminal records check, as well as a national criminal records check, if available child protective services check and sex offender registry, as appropriate and permissible by state law. I understand that the information requested in this application will be used only for the purpose of determining suitability as a CASA volunteer. I understand that CASA reserves the right to reject this application if the applicant not deemed appropriate for any reason.

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 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 volunteer guardian ad litem. I will discuss these matters only with those directly involved in the case or who will be consulted for their professional knowledge and expertise.

A refusal of signature will automatically result in a rejection of this application. Please e-mail completed application to casakids@.

Name (printed)     

Signature____________________________________ Date___________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download