CASA Information Packet
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Child Advocate Volunteer Application
Volunteer Application (p. 2-4)
Personal References (p. 5)
Criminal History Information (p. 6)
Permission to Allow Child Protective Services and DPS History Check (p. 7)
Volunteer Acknowledgement & Release for Background Checks (p. 8)
Copy of Driver’s License (please include with this application)
Schedule a fingerprinting appointment (please see “Background Screening” document available on )
Which type of Training Class would you like to attend?
Daytime
Saturdays & Evenings
Flex
(A Training Schedule is available online at )
The criteria used to select volunteers of CASA Child Advocates of Montgomery County are designed to ensure that the individual is able to meet the responsibilities of a CASA volunteer. No individual will be excluded on the basis of race, color, religion, national origin, gender, age, or disability.
You may submit this application by fax, email, or mail.
How did you hear about Child Advocates of Montgomery County?
Texas CASA Website National CASA Website
Internet: School:
Billboard: Banner/Flyer/Brochure:
TV/Radio: Newspaper:
Referred by/Heard from: Event/Presentation:
Other:
General Information
|Date |Date of Birth - - |
|Last Name |First |
|Address |Apt. No. |
|City |State |Zip Code |
|Have you lived outside of Texas within the past seven years? |
|If yes, please list the city and states you have lived in over the past seven years: |
| |
| |
|Primary Number - - |Secondary Number - - |
|E mail Address |
Demographic Information
Please check the appropriate box.
Marital Status Single Married Widowed Divorced Partner
Education High School Diploma Some College College Degree
Post Graduate PhD/MD Other
Languages English Spanish Other
Spoken
Family Information
(If Applicable)
Name of Spouse/Partner: Spouse/Partner Employer:
Children’s Names & Ages:
Other Members’ of Household Names & Ages
Employment/Volunteer History
Employment Full Time Part Time Retired Self-Employed
Status Student Homemaker Unemployed
Employment History, starting with most recent:
|Company Name |Position |Contact Information |Employment Dates |
| | | | |
| | | | |
| | | | |
Please list any relevant work or volunteer experience with children.
Please list any other current community activities and memberships in any clubs, churches and other organizations.
Personal Background Information
1. Have you had any personal experience involving the following?
Please check all that apply. Family includes parents, grandparents, siblings and children.
|Type of Abuse |Self |Family |
|Sexual Abuse | | |
|Physical Abuse | | |
|Emotional Abuse | | |
|Neglect | | |
|Exposed to Domestic Violence | | |
|Involved with Children’s Protective Services | | |
|Substance Abuse | | |
|(Drugs, Alcohol, Prescriptions, Inhalants, etc…) | | |
2. If you placed an “x” in any of the preceding questions, please explain below. Please include how you addressed these experiences.
3.If you placed an “x” in any of the preceding questions, how do you think these experiences will impact your work with Court Appointed Special Advocates of Montgomery County?
All CASA volunteers must have a valid driver’s license and current automobile liability insurance. Volunteers must provide the CASA office with a copy of a current driver’s license in order to process your application.
Do you have a current valid Texas driver’s license? Yes No
Do you have access to a car? Yes No
Volunteer Essay
Please provide a brief autobiography which includes any historical information you feel shaped your life. Include information about your childhood, current lifestyle (career, family, hobbies, interests), and the reasons which led you to apply to volunteer with CASA.
Personal References
Please list four personal references. Volunteers must have 3 references submitted prior to completing
pre-service training in order to take a case.
▪ Please inform references that they will be contacted within 48 hours of submitting this application.
▪ Please provide a complete email address where a reference questionnaire may be sent.
▪ References from relatives are not acceptable.
Reference 1
Name
Phone Number (work / home) E Mail Address
Relationship to Volunteer Applicant
Reference 2
Name
Phone Number (work / home) E Mail Address
Relationship to Volunteer Applicant
Reference 3
Name
Phone Number (work / home) E Mail Address
Relationship to Volunteer Applicant
Reference 4
Name
Phone Number (work / home) E Mail Address
Relationship to Volunteer Applicant
I have contacted these references prior to submitting them in this application.
Criminal History Information
I have read this form in its entirety and understand that the information will be verified by Child Advocates of Montgomery County, and that the inclusion of any false information or the omission of any requested information is cause for my immediate dismissal by Child Advocates of Montgomery County. I understand that Child Advocates of Montgomery County will ask all volunteers to complete criminal records fingerprint check which will reveal any arrest, charge, or conviction. (The fact that you have completed deferred adjudication or that your arrest, charge, or conviction has been dismissed, vacated, pardoned, or expunged does not mean you can answer “no”. Failure to disclose any and all information regarding your criminal history could result in non-acceptance to the program or dismissal from the training program should undisclosed criminal history be discovered during that time period. I agree to inform Child Advocates of Montgomery County if this information changes. Any applicant found to be convicted, or having charges pending for, a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children or the CASA program’s credibility is not accepted as a CASA volunteer.
I acknowledge that I am providing the following information related thereto:
1. I have have not been charged or convicted of a felony or a misdemeanor. If your answer is affirmative (i.e.: you HAVE been charged or convicted), please give details below:
|Date |Offense/Nature of Charge or Conviction |Location |Details & Disposition |
| | | | |
| | | | |
| | | | |
2. I am am not currently under indictment or charged in an official criminal complaint accepted by a district or county attorney with a felony or misdemeanor. If your answer is affirmative (i.e.: you ARE under indictment), please give details below:
|Date |Charges |Location |Details |
| | | | |
| | | | |
| | | | |
I understand that I will not receive reimbursement for my fingerprint check if I do not disclose my criminal history in this application, or if Child Advocates of Montgomery County determines my criminal history and/or Child Protective Services history disqualifies me from becoming a CASA volunteer. I understand that I will receive my reimbursement only upon completion of the 30+ hour training program and official swearing in as a CASA volunteer.
Name (Please Print)
Signature of Volunteer Date
|Texas Dept of Family |PERMISSION TO ALLOW CASA PROGRAM TO REQUEST CHILD ABUSE/NEGLECT | Form 2970a |
|and Protective Services |CENTRAL REGISTRY and DPS CRIMINAL HISTORY CHECK |May 2010 |
|First Name |Middle Name |Last Name |
| | | |
|Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last (continue on back as needed) |
| |
|E-mail Address (optional) |
| |
|Residence Street Address |City |County |State |Zip Code |
| | | | | |
|Residence Telephone No. (A/C) |Date of Birth |Gender : |SSN |
| | |Male Female | |
|Race (check all applicable) |Ethnicity (check one, only) |
|Am Indian/AK Native Nat Hawaii/Pacis |Hispanic |
|Asian White |Not Hispanic |
|Black Unable to Determine |Unable to Determine |
|List all addresses you have resided in Texas: |
| |
| |
| |
| |
| |
| |
| |
|I am the person listed above. The information in this document is correct and I am a prospective or current volunteer, employee or board member of a |
|Court Appointed Special Advocate (CASA) program. I agree to update the CASA program of any changes to the information above. |
| |
|I grant permission to the CASA program to request a Child Abuse/Neglect Central Registry and a Texas Department of Public Service Criminal history |
|check as well as any subsequent checks so long as I am active with the CASA program. |
| |
|I understand that the information I am providing will be part of any request and that providing false information is a violation of Texas Penal Code |
|Section 37.10. |
| |
|Signature: _________________________________________ |
| |
|Date of Consent:____________________________________ |
REQUIRED IDENTIFYING INFORMATION ON SUBJECT OF REQUEST - The requester must provide all of this information in order for a check to be made:
Volunteer Acknowledgement Form & Release for Criminal Background Checks
I hereby certify that the information submitted in this application is correct and accurate to the best of my knowledge. I hereby authorize Child Advocates of Montgomery County to investigate my background as part of the screening process to determine my fitness / appropriateness as a potential volunteer. I authorize Child Advocates of Montgomery County to secure the following record checks: Social Security number verification; criminal records from the court jurisdiction in which I currently reside and work; state criminal records; FBI or other national criminal database; National Sex Offender Registry; and, Child Abuse Registry or Child Protective Services check where permissible by law. I give my permission for my references to be checked which may include past employers, volunteer organizations and personal references. I understand that all the information will be held in strict confidence and used only for the purpose of determining my suitability as a volunteer. I understand that not all applicants who apply to be a volunteer are chosen to participate in the program and that Child Advocates of Montgomery County reserves the right to deny an applicant into the volunteer program for any reason. If a volunteer applicant refuses to sign a release of information form or submit the required information or fingerprints for any of the checks required, the CASA program will reject the applicant.
I understand that qualities of a successful CASA volunteer include interpersonal skills, compassion, punctuality, and reliability. I further understand that if concerns arise, CASA reserves the right to reject an applicant at any time, including during the training process or after certification.
As a CASA Montgomery County volunteer I will be willing to: (Please check each box for “Yes”)
Commit a minimum of a year to being a CASA volunteer
Complete CASA’s 30+ hour volunteer training program
Participate in 12 hours of continuing education training yearly
Visit in person at least monthly with the child(ren) to which I may be assigned
Prepare written reports to the court with guidance from CASA staff
Participate and attend court hearings and meetings on my child’s case during regular business hours
Record and turn in a monthly log of my activities on my case.
If unforeseen circumstances prevent me from fulfilling this goal, I will submit my written resignation to the Program Director with as much advance notice as possible.
_____________________________________________________________________________________
Name (Please Print)
_____________________________________________________________________________________
Signature Date
Thank you for completing this volunteer application for CASA Child Advocates of Montgomery County!
After reviewing your application, you may submit it by email (Volunteer@), fax (936.760.4180), or mail (412 W. Phillips St, Ste 107, Conroe TX 77301).
The Screening Process
For every Child Advocate, the screening process begins with an application and includes passing a criminal history check and a Child Protective Services background check.
CRIMINAL HISTORY CHECK
A criminal history check is comprised of local, state, and national arrests or convictions of misdemeanor or felony charges in addition to sex offender checks and Social Security Number verification. The results will allow the Director of Recruitment and Training to determine a candidate’s eligibility to volunteer. Please follow these steps, reading thoroughly, before beginning the process.
At this time, the cost of this check is $39.95. CASA will reimburse all applicants for this cost if all of the following conditions are met:
1. You have disclosed all criminal history on your application
2. You do not have criminal history which would disqualify you, at the discretion of the Director of Recruitment and Training, from serving as a CASA Child Advocate.
3. You keep the FAST Fingerprint Pass that is signed by the Enrollment Agent at your appointment, for $39.95, and submit to Wanda Smith before the end of your training class
4. You complete Pre-Service Training and are sworn in as a CASA Child Advocate
We do not wish to exclude anyone from service on the basis of this expense. If, for any reason, you would like to discuss possible alternatives, please contact the Director of Recruitment and Training.
How do I complete this check?
Step 1. Print and fill out the “FAST Fingerprint Pass” for National Child Protection Act (NCPA). Be sure that the ORG ID # is 21564 and CASA-Montgomery County, INC (NCPA) is listed.
Step 2. Follow the directions at the top of the “FAST Fingerprint Pass” to schedule a fingerprinting appointment at any location. Please make your appointment at least 5-7 days before the first day of the training class you choose to take.
Step 3. Bring your FAST Fingerprint Pass, a check or money order payable to MorphoTrust (they do not accept credit or debit cards), and your driver’s license to your appointment. Please arrive early as missing your appointment will force you to reschedule for another time and/or date.
Step 4. Retain and submit your FAST Fingerprint Pass, completed by the fingerprinting office, to the Director of Recruitment and Training for reimbursement.
IMPORTANT:
• If you have CPS history or criminal history which may prevent you from serving as a CASA Volunteer, DO NOT schedule a criminal history check without first consulting the Director of Recruitment and Training
• You will only be reimbursed the cost of the checks which are pre-selected for you by choosing NCPA and listing the CASA ORG ID. Unless you select additional services, the price at your checkout should be exactly $39.95
• To Loop 336, Conroe location: Exit I-45 onto N. Loop 336 E and drive 2.2 miles. Once you pass the Tri- County building on the right, the fingerprinting office will be immediately on the left. It is located in what looks like a home with a black and white sign that says "Fingerprinting". To be sure you do not miss your appointment, please print directions from a website (such as MapQuest or Google Maps) and leave with adequate time.
• If you are unsure about ANYTHING at any point, please contact the Director of Recruitment and Training. CASA cannot be responsible for the cost of appointments which do not provide all necessary checks, do not designate CASA as the recipient, or are made in error
CHILD PROTECTIVE SERVICES (CPS) CHECK
This allows CASA to know if you have previous history with CPS of a nature which would preclude you from working directly with the children CASA serves. Once the Child Advocate Application is completed legibly with physical signatures and submitted to CASA for processing, you will not need to take further action.
IN STATE APPLICANT
National Child Protection Act (NCPA)
This document is your FAST Fingerprint Pass for a state and national criminal history record check. Please schedule a fingerprint appointment by visiting or by calling 1-888-467-2080. When scheduling an appointment you will be prompted by IdentoGO for the following additional personal data: Date of Birth, Sex, Race, Ethnicity, Skin Tone, Height, Weight, Eye Color, Hair Color, Place of Birth and Home Address. During your Fingerprint appointment you will also be prompted for Social Security Number and Driver License Number. Requested data is required by the Texas Department of Public Safety to process your background check. These data elements have been omitted from this document in order to better protect the security of your personal information. You may pay for FAST services online with a credit card or onsite with a check or money order only. Your fingerprints will be submitted to the Texas Department of Public Safety and the Federal Bureau of Investigation.
1. Logon to
2. Select: Texas
3. Select: Online Scheduling
4. Select: English or Espanol
5. Enter: First and Last Name
6. Select: NCPA
7. Select: Volunteer or Employee/Contractor
8. Enter: ORG ID # (see below)
9. Follow the prompts to enter requested information.
10. Bring this completed form with you to your appointment.
Section One: Qualified Entity Information
ORG ID #: __21564_______________ Your Qualified Agency/Entity/Organization: __CASA-Montgomery County, INC (NCPA)_____________
Your Qualified Entity/Organization Contact Person: _Wanda Smith_________________________ Original TCN: __________________________
(If resubmission for rejected fingerprints)
Section Two: Applicant Name (To be completed by applicant)
Last: ______________________________________ First: _________________________________ Middle: ________________________
(Please print) (Please print) (Please print)
Section Three: Waiver Information (To be completed and signed by applicant)
I ______ have OR ______ have not been convicted of a crime. If convicted, describe the crime(s) and particulars in the space below:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
I certify that all information I provided in relation to this criminal history record check is true and accurate. I authorize the Texas Department of Public Safety (DPS) to access Texas and Federal criminal history record information that pertains to me and disseminate that information to the designated Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, through the DPS Fingerprint-based Applicant Clearinghouse of Texas and as authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute or policy.
I authorize the Texas Department of Public Safety to submit my fingerprints and other application information to the FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to the application. I authorize the FBI to disclose potentially pertinent information to the DPS during the processing of this application and for as long hereafter as may be relevant to the activity for which this application is being submitted. I understand that the FBI may also retain my fingerprints and other applicant information in the FBI’s permanent collection of fingerprints and related information, where all such data will be subject to comparisons against other submissions received by the FBI and to further disseminations by the FBI as may be authorized under the Federal Privacy Act (5USC 552a(b)). I understand I am entitled to obtain a copy of any criminal history record check and challenge the accuracy and completeness of the information before a final determination is made by the Qualified Entity. I also understand the Qualified Entity may deny me access to children, the elderly, or individuals with disabilities until the criminal history record check is completed. If a need arises to challenge the FBI record response, you may contact the agency that submitted the information to the FBI, or you may send a written challenge request to the FBI's Criminal Justice Information Services (CJIS) Division at FBI CJIS Division, Attention: Correspondence Group, 1000 Custer Hollow Road, Clarksburg, WV 26306.
Signature: ______________________________________________________ Date: __________________________________________
Section Four: Service Center Information (To be completed by FAST Enrollment Agent)
Date Prints Taken _______________________ Amount Charged For Service: Amount charged for service may vary by option selected
Paid by: ( Check ( Money Order ( Visa ( MasterCard ( Billing Acct
TCN: ____________________________________________________________
I HAVE COMPARED THE GOVERNMENT-ISSUED IDENTIFICATION PRESENTED BY THE APPLICANT AND ATTEST THAT TO MY BEST DETERMINATION; I HAVE FINGERPRINTED THE SAME PERSON.
E.A. Name: ________________________________________________ E.A. Signature: ________________________________________________
(Please print)
Revised 04/13[pic][pic]
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Mail 412 West Phillips
Suite 107
Conroe, TX 77301
Email Wanda@
Phone 936.441.5437, ext. 209
Fax 936.760.4180
Web
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936.441.5437, ext. 209 | | Volunteer@
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