Gibson County CASA Volunteer Application

Qualifications and Personal Information

Gibson Circuit Court Court Appointed Special Advocate (CASA) Program VOLUNTEER CERTIFICATION APPLICATION Any willful omission or misrepresentation of any fact required to be disclosed in this application or any accompanying statement may result in certification (initial or ongoing) denial. This is pursuant to the Administrative Code Sections governing Court Appointed Special Advocates in Gibson County

Qualifications

I am at least 21 years of age.

Yes
No

I am a U.S. Citizen or a Legal Resident

Yes
No

Personal Information

Full Name

AKA

SSN

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Gender

Male
Female
Other/Decline

Main Phone

Hispanic

Yes

Cell Phone

Race

Work Phone

Home Email

Best Phone

Work Email

Marital Status

Primary Language

Add Education (Type/Degree/Major)

Additional Language

Emergency Contacts

Name

Phone

Relationship

Experience

Child Protective Agencies

Yes
No

If yes, Explanation:

Foster Care

Yes
No

If yes, Explanation:

Juvenile Court

Yes
No

If yes, Explanation:

Other Child Service Agencies

Yes
No

If yes, Explanation:

Child Abuse or Neglect

Yes
No

If yes, Explanation:

Domestic Violence

Yes
No

If yes, Explanation:

Mental Illness/Mental Health Treatment

Yes
No

If yes, Explanation:

How did you hear about our program?

Volunteer Experience

Organization Name

Supervisor Name

From Date

To Date

Responsibilities

Reason for Leaving

Employment

Employment History

Career Type

Status

Current Employer

Job Title

Work Hours

Company

Supervisor Name

Phone

Permission to Contact

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reponsibilities

Vehicle Information

Do you have access to a vehicle

Yes
No

Driver's License Number

State

Expiration Date

Auto Insurance Company

Expiration Date

Background Information

Background

If you answer "yes" to any of the following questions, please provide a brief narrative.

Applicants who are employed by child welfare agencies may serve as a CASA volunteer if authorized by the Circuit Court Judge. Are you employed by the court or a child welfare agency?

Yes
No

If yes, Explanation:

Have you ever had disciplinary action taken against you by any state or federalcourt, administrative or regulatory agency?

Yes
No

If yes, Explanation:

Has there been a finding against you in a civil, probate, domestic relations, or dependency or other court case, that you have sexually assaulted, exploited, or physically abused any child or vulnerable adult?

Yes
No

If yes, Explanation:

Have you used any non prescribed controlled substances and or illegal drugs, including marijuana, within the past two (2) years?

Yes
No

If yes, Explanation:

If you provided educational information, would you please provide the names and year obtained of the institutions associated with your education?

Yes
No

If yes, Explanation:

Do you have any prior experience working with children? If yes, please brief describe it for us.

Yes
No

If yes, Explanation:

Please provide a brief statement explaining why you want to work with the CASA Program.

Criminal History

If you answer "yes" to any of the following questions, please provide a brief narrative.

Have you ever been convicted of any crime in this state or any jurisdiction?

Yes
No

If yes, Explanation:

Do you have any charges pending or are you currently awaiting trial for any felony?

Yes
No

If yes, Explanation:

Have you ever been convicted of a felony?

Yes
No

If yes, Explanation:

Are you currently on Probation, parole, or community supervision for a felony offense?

Yes
No

If yes, Explanation:

Personal References

We will be contacting your references by either mail, phone, or email. Please be sure to provide current contact information.

Reference 1

Name

Relationship

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2

Name

Relationship

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3

Name

Relationship

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Agreement

I am interested in becoming a CASA volunteer and know of no reasons why I should not be assigned to a child in the CASA program. I am aware that the children CASA has been assigned to have been abused, neglected or abandoned by adults and/or may not have had adults they count on. I acknowledge that I will make a commitment of one year to the child(ren) and case to which I may be assigned.

Release

I understand that background investigations including criminal history, DCS background checks, and State and Local Registry, Central Registry information are some of the screening procedures and are conducted on allapplicants. I consent to the back ground check and allcomponents stated above for the purpose of aiding such a background investigation. I agree to submit to the procedure with the knowledge that the results of the investigation are a determining factor in the Court Appointed Advocate Process.

In submitting this application, I further agree to abide by allconfidentiality laws as of the date of this application. I understand that my application does not ensure acceptance into the program. I also understand that the Gibson County CASA Program reserves the right to disqualify any applicant who would not be a good match for this volunteer position. Service as a CASA Volunteer is by grace not by right.

The filing of an application which is false or misleading may result in denial or suspension.

I affirm the statements on the application are true and correct. I have disclosed allaspects of my criminaland background history that would affect my participation in the program.

Thank You

We appreciate your time and effort in completing the Gibson County CASA Volunteer application. Your application will be reviewed by a member of our staff and you will be contacted soon. Please take a moment and let your references know that our office may be contacting them by phone, or to expect a link to our reference survey, if you provided emailaddresses.