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Application for CASA Program
  Name:
  Address:
  Telephone #:
  Work/Cell #:
  Email address:
  May you be called at work? Yes No
  How long have you lived in: county? years.
  Date of Birth:
 
  Marital Status:  
  If currently married, spouse's name
  Spouse's Occupation:
Children:
    Name:
    Date of Birth:
    Sex:
    Name:
    Date of Birth:
    Sex:
  Other members of household:  
    Name:
    Date of Birth:
    Sex:
  Do you drive? Yes No
  Do you have an automobile available to you? Yes No
  What is the current status of your health?  Do you have any physical or mental conditions, which would interfere with any essential elements of your duties as a volunteer?  
  When would you be available for volunteer service? Check times..
  Morning  
Afternoon
Evening   		Mon. 
Tues.
Wed.
Thurs.
Fri.   
Sat.  
Sun.  
  Approximately how much time can you contribute weekly as a CASA Volunteer?  
Would you feel comfortable visiting with children in private homes, foster care homes, institutions, and/or group homes? Yes       No
Are you prepared to complete CASA training and participate in ongoing continuing education? Yes       No
Are you prepared to commit to the assigned case until permanency is achieved? Yes       No
Are you prepared to commit time to participate in court hearings, team meetings, and case reviews? Yes       No
  Do you have any training or experience in any of the following?
  Medicine Education
  Mental Health News Media
  Child Development Writing and Public Speaking
  Drugs or Alcohol Abuse Program Child Care
  Advertising or Public Relation Art & Graphics
  Psychology Social Work
  Law Enforcement Counseling
  Criminology  
  If you checked any please describe:
Have you had any personal business or communication with the Tennessee Department of Children’s Services (DCS) or any other child welfare agency? Yes    No
  Have you ever been arrested for a crime, especially any crime in which children may have been involved? Yes  No
  What charges?
  Date of arrest Where?
Your Education (Check highest completed)
  High School 9 10 11 12
  College 1 2 3 4
  Graduate 1 2 3 4
  Major:
  Degree:
  Work/ Volunteer History

Include Names and Addresses of last volunteer project. Also include dates, supervisor names, and description of work.
  1.
  2.
  3.
  Can you think of any reason Judge Christy R. Little might be reluctant to appoint you to the case?
  No If yes, Why?
  Yes
  How did you learn about the CASA program?
Describe experiences working with children?  
What experience or knowledge of children and families do you have that will assist you in determining what may be in a child’s best interests? Please describe here any experiences you have had working with children that are not included in your work/volunteer history above.
  Explain why you want to work with the CASA program.
Personal References:

Please list three references that are not family members. References should have knowledge of how you interact with children.
1. Name:
   Address:
   Telephone:
   Relationship:
2. Name:
   Address:
   Telephone:
   Relationship:
3. Name:
   Address:
   Telephone:
   Relationship:
In case of an emergency, contact: Name and Telephone #

List other current community activities and memberships in clubs, church, other organizations:

What languages do you speak?
Hobbies/Special Interests:
AFFIRMATION AND AUTHORITY TO
RELEASE INFORMATION
I,  , hereby affirm that all the answers provided on my volunteer application are true. I hereby authorize MADISION COUNTY CASA to investigate my background to determine my fitness as a potential volunteer.

I understand that the information requested in this application will be used only for determining suitability as a CASA volunteer. 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 document, reports, and other materials I will examine in my capacity as a volunteer CASA. I will discuss these matters only with those persons directly involved in the case or who will be consulted for their professional knowledge and expertise.

I hereby authorize a representative of the CASA program to conduct an investigation on my background in conjunction with other official duties. This will include national, state, and local criminal records checks. At minimum the program will do a criminal records check with the Sheriff’s Department located in each county of residence for the past seven years nationwide; checks of the online databases for felony offender, sex offender, methamphetamine offenders, and abuse registry; and a fingerprint check through the Tennessee Bureau of Investigation and the Federal Bureau of Investigation.

I further authorize any law enforcement agency to conduct a criminal record check and to release the results of said criminal record check to the CASA program. This release is executed by me with the full knowledge and understanding that the information to be obtained about me is for office use of the CASA program.

In accordance with National CASA and Tennessee CASA standards, Madison County CASA must reject any volunteer applicant whose criminal records check shows a conviction for or pending charges of sexual offenses, child abuse or neglect, or related acts that pose a risk to children or to Madison County CASA’s credibility as a community service agency.

I have read the above waiver and release statement and fully understand what rights I am waiving by signing this document.
FULL NAME
Sex:  Male Female
Date of Birth:

Copyright 2007 Madison County CASA