CASA of Contra Costa County

Thank you for your interest in becoming a CASA Volunteer! Please verify accuracy all fields before submitting.

You may drop off or mail your packet to:

CASA of Contra Costa County
2151 Salvio Street, Suite 295
Concord, CA 94520
(925) 256-7284

Personal Info

(* required fields)

Date*

First Name*

Last Name*

Are you known by any other names?

Home Address*

City*

State*

Zip

Home Phone*

Cell Phone

Work Phone

Fax Number

Email*

Date of Birth*

Place of Birth

Sex

Drivers License

State

Please be aware you will be required to submit proof of automobile insurance.

Are you computer Literate?

Ethnicity

Where did you hear about the CASA Program?

Current hobbies and / or interests

How would you describe your personality?

Current Marital Status

Status

Date

Spouse's / Partners Name

Date of Birth

Spouse�s Employment and Position

Children's Names

Name

Date of Birth

Living With You?

Yes

Emergency Contact

Name

Phone

Relationship:

Employment History

Company Name

Position

Supervisor

Phone

From

Company Name

Position

Supervisor

Phone

From

Company Name

Position

Supervisor

Phone

From

Present Employment Status

Hours Per Week

Education

Select Highest Completed

High School

College

Graduate School

Major

Degree

Currently Enrolled in School?

Part or Full Time?

Exp. Grad Date

Will you receive academic credit for your volunteer work?

Yes

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?

Yes

If yes, please give organization names and details

Do you give the Tennessee CASA Association permission to obtain information from these organizations regarding your membership?

Yes

If No, please explain

Have you or your family had personal/professional experience with:

Child Abuse

Yes

Foster Care

Yes

Juvenile Court System

Yes

Child Protective Services

Yes

If yes, please explain (include date and location in explanation

Other Child Service Agencies

Yes

Counseling or Therapy

Yes

Have you ever applied with another organization that works with children?

Yes

Were You Accepted

Yes

Please give name(s) of organization(s) & year

Have you ever applied to this or any other CASA program before?

Yes

IF yes, explain

Please answer the following questions and give details if answer is yes:

Have you ever been arrested for a crime?

Yes

If yes, what charge? Please describe/explain.

Please Include:
Date of arrest

Location of arrest/arraignment

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?

Yes

Details

Do you now, or have you had a drug/alcohol abuse or dependency problem?

Yes

If yes, please expand in terms of "when" and identify recovery process

Do you have any kind of health impairment?

Yes

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?

Yes

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.

Name

Phone

Address

City

State

Zip

Relationship (how this reference knows you)

Name

Phone

Address

City

State

Zip

Relationship (how this reference knows you)

Name

Phone

Address

City

State

Zip

Relationship (how this reference knows you)

Name

Phone

Address

City

State

Zip

Relationship (how this reference knows you)

Do you have any training or experience in any of the following: (please check all that apply)

Medicine

Mental Health

Psychology/Counseling

Fund Raising

Child Development

Drug/Alcohol Abuse Programs

Child Care

Child Welfare

Social Work

Education

Criminology

Law Enforcement

News Media

Writing

Advertising/Public Relations

Public Speaking

Art or Graphics

Foreign Language

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, hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize CASA, Inc., and any law enforcement agency they authorize, 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 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.

Print Full Name*

Date

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Personal Info

(* required fields)

Current Marital Status

Children's Names

Emergency Contact

Employment History

Education

Select Highest Completed

Personal

Have you or your family had personal/professional experience with:

Please answer the following questions and give details if answer is yes:

Please respond to the following:

References

Please provide COMPLETE contact information for three non-family references that have known you for at least one year.

Background Check

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