Volunteer Application – Decatur County CASA

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Work/Cell

Email*

May you be called at work?

Yes
No

County*

How long have you lived in this county?

Date of Birth

Marital Status*

If currently married, spouse's name

Spouse's Occupation:

Children

Name

Your child's name

Date of Birth

Sex

Name

Your child's name

Date of Birth

Sex

Other members of household:

Name

Other household member's 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?

Volunteer Time

When would you be available for volunteer service?*

Morning
Afternoon
Evening

Check days:*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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

Experience

Do you have any training or experience in any of the following?

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?

Education

High School*

9
10
11
12

Check highest level completed

College

1
2
3
4

Check highest level completed

Graduate

1
2
3
4

Check highest level completed

Major/Degree

Work/Volunteer History

1*

2

3

Can you think of any reason a Judge might be reluctant to appoint you to the case?*

Yes
No

If yes, why?

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 include the following: Name/Address/Telephone/Relationship

1*

2*

3*

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

In case of an emergency, contact:*

Name and Telephone #

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 DECATUR 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, Decatur 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. I understand that I must complete a TBI/FBI Fingerprint Criminal Background Check prior to beginning training. I understand that the cost of this check is $40. I understand that I am responsible for full payment of this $40 at the time my fingerprints are taken.

Full Name*

*This information is required for the TBI/FBI Criminal Background Check.

Sex

Male
Female

Height*

Weight*

Hair Color*

Eye Color*

Date

Signature