Personal Info
(* required fields)
Please be aware you will be required to submit proof of automobile insurance.
Current hobbies and / or interests
Current Marital Status
Status
Single
Committed Relationship
Married
Widowed
Divorced
Separated
Children's Names
Name
Date of Birth
Living With You?
Emergency Contact
Employment History
Education
Select Highest Completed
High School
None
9th Grade
10th Grade
11th Grade
12th Grade
College
None
1 Year
2 Years
3 Years
4 Years
Graduate School
None
1 Year
2 Years
3 Years
4 Years
Will you receive academic credit for your volunteer work?
Personal
List any community groups in which you are presently active (professional associations, faith communities, service organizations, etc)
Do you have any experience working with children?
If yes, please give organization names and details
Do you give CASA of Westmoreland permission to obtain information from these organizations regarding your membership?
If No, please explain
Have you or your family had personal/professional experience with:
Child Protective Services
If yes, please explain (include date and location in explanation
Other Child Service Agencies
Have you ever applied with another organization that works with children?
Please give name(s) of organization(s) & year
Have you ever applied to this or any other CASA program before?
IF yes, explain
Please answer the following questions and give details if answer is yes:
Have you ever been arrested for a crime?
If yes, what charge? Please describe/explain.
Disposition of case
Do you have any mental health problems/issues/concerns that you are currently being treated for or have been in treatment for in the past?
Details
Do you now, or have you had a drug/alcohol abuse or dependency problem?
If yes, please expand in terms of "when" and identify recovery process
Do you have any kind of health impairment?
Details
Please respond to the following:
I am interested in working with children and families as a CASA volunteer because . . . .
I feel I can be a fair and objective advocate for a child because . . .
Any hesitations or concerns regarding my participation in the CASA program at this point are. . .
Are you willing to commit to 18 months of volunteer service?
CASA volunteers give 15-20 hours a month. When would you fit this time into your schedule?
Please give a short account of the role you believe society should play in protecting the rights of children and in helping a family overcome hardships and remain together. Also include your feelings regarding the rights and responsibilities of parents and children.
References
Please provide COMPLETE contact information for three non-family references that have known you for at least one year.
Please do not list a relative or significant other. If possible, please list an employer or supervisor. CASA of Westmoreland will mail a brochure with a description of the CASA program and reference form for them to complete and return.
Do you have any training or experience in any of the following: (please check all that apply)
If you answered yes to any, please describe/explain
Background Check
Any applicant found to have been convicted of 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 eligible to be a CASA volunteer.
I,
I understand that the information requested in this application will be used only for the purpose of determining my suitability as a CASA volunteer. Further, I understand that completion of training does not guarantee that I will be assigned a case. If I have successfully completed the training and have met all other requirements, and it has been determined that I am a suitable volunteer, I understand that 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 CASA volunteer. 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 also understand that if for any reason it becomes apparent that my activities are contrary to the policies, goals and/or philosophy of the CASA program, and their desire to provide quality services to abused and neglected children, my services as a CASA volunteer will be terminated.
I submit the statements on this application are true, complete, and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or can result in dismissal at a later time.
Captcha: (please answer the following question to submit your request)
What is the sum of 10 + Fifteen ?