CASA Volunteer Application for Southeast Mississippi

Volunteer Application

Personal Information
Experience & Employment History
Background and Criminal History
Personal References

Qualifications

Are you at least 21 years old?

Yes

Personal Information

First Name

Middle Name

Last Name

Date of Birth

Gender

Male

Female

City of Birth

State of Birth

Race

Primary Language

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone Number

Work Phone Number

Highest School/Education Completed

Degree/Training Received

Do you drive?

Yes

Do you have available transportation?

Yes

Emergency Contact Information

The second contact is in case of a natural disaster such as a hurricane.

Emergency Contact

First Name

Last Name

Cell Phone Number

Relationship

Experience

Please tell us about any personal and/or professional experience you have with thefollowing agencies, organizations, or areas. You are not required or expected to have any experience in these areas to be a volunteer.

Child Protective Services

Yes

Please explain the experience you have with child protective services

Foster Care

Yes

Please explain the experience you have with foster care.

Juvenile Court

Yes

Please explain the experience you have with juvenile court.

Other Child Service Agencies

Yes

Please explain the experience you have with other child service agencies.

Child Abuse Or Neglect

Yes

Please explain the experience you have with child abuse or neglect cases.

Domestic Violence

Yes

Please Explain experience you have with domestic violence cases.

Mental Illness/Mental Health Treatment

Yes

Please explain experience you have with mental illness/mental health treatment.

How did you hear about the program?

Volunteer Experience

Please tell us about any personal and/or professional experience you have with community volunteer organizations.

Volunteer Supervisor

Full Name

Organization Name

Current or Most Recent Employment

Job Title

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

Responsibilities

Supervisor’s Name

Is this your current or most recent employment?

Current

Most Recent

What was your reason for leaving?

What are (or were) your work hours?

Do we have permission to contact this employer?

Yes

Employer Phone

What are your reasons for wanting to participate as a CASA volunteer?

Background Information

Are you currently a resident of Jackson, George or Greene County Mississippi?

Yes

If yes, please tell us how long you have lived in Jackson George or Greene County.

If you are not a resident, please explain.

Have you lived anywhere besides your present address in the past seven (7) years?

Yes

Please list all home addresses from the past seven (7) years.

Criminal History

An applicant having a charge or convictions for a crime involving a sex offense or child abuse or neglect is disqualified as a volunteer. Applicants with other misdemeanor or felony charges or convictions that would not pose a risk to children or negatively impact the credibility of the program will be considered on a case-by-case basis considering the time passed since the incident and the level of rehabilitation. Please answer the following questions. If YES, please explain.

Have you ever been convicted of a crime other than a minor traffic violation?

Yes

If yes, what was the charge?

Date of Conviction

Court or City Where Convicted

Can you think of any reason why a judge or anyone else might be reluctant for you to serve as a CASA volunteer?

Have you or any family member or relative been involved in the Youth Court?

Yes

If yes, please explain.

Personal References

Please list three (3) references of people who know you well, other than relatives, preferably for whom you have worked in either a paid or voluntary capacity. If you are currently working, either paid or as a volunteer, please include the name of your supervisor.

References

Full Name

Relationship

Phone Number

Address

City

State

Zip

CASA of Southeast Mississippi, Inc. reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All information obtained will beheld in the strictest confidence

Background Check Consent

I consent to a routine check of my criminal records.

Volunteer Service Commitment

I am willing to commit to eighteen (18) months of volunteer service.

Volunteer Commitment

As a CASA volunteer you will be required to attend Court Hearings for the children you represent.

Scheduling Commitment

I will be able to arrange my schedule to attend these hearings.

Rejection of Applicant

CASA of Southeast Mississippi, Inc. reserves the right to reject the volunteer applicant if, but is not limited to, the following reasons:

If he/she refuses to sign release of information.
If the applicant is 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.

Signature