If you have troubles with this form, please contact volunteer@sbcasa.org or call 805-357-2590. CASA Volunteer Application I am over 21 years old and have read the information about and want to become a volunteer:* Yes No You must be over the age of 21 in order to become a CASA volunteer. To find additional ways to get involved, please email info@sbcasa.org First name* Middle Name* Last name* E-mail address* I am willing to serve on a case in (select all that apply): Santa Barbara/ Goleta/ Carpinteria Santa Maria/ Guadalupe Lompoc/ Santa Ynez Valley I can serve anywhere in the county Other ways you can help Thanks to our current pool of active volunteers, at this time we are only accepting volunteer applications from those who can serve a child in the Santa Maria or Lompoc area. Please consider other ways you can be involved. Phone # I would still like to help by: Serving a child waiting in Ventura County Serving on a committee Helping to raise awareness Joining the Circle of Hope (monthly giving program) Donating to CASA Personal Information Maiden / Prior name / AKA Date of birth* Home address* City* State* Zip code* Primary phone* Secondary phone Drivers license #* State Marital status* Single Married Widowed Divorced Gender Male Female No. of children Spouse's name Spouse's occupation Address Phone Do you have auto insurance? Yes No Insurance company Policy number Policy Expiration Date Other member of household Relationship to you Other member(s) of household Relationship to you Emergency Contact Name Relationship to you Address Phone Employment Information Current employment status* Please select Employed Unemployed Retired Homemaker Employer's name Previous employer's name Address Work Phone Work e-mail Supervisor May we call and/or e-mail you at work? Yes No Title and brief description of work Describe any personal or employment constraints that may restrict your availability How long have you been with your current employer? Less than 6 months 6 months to 1 year 1-3 years 3-6 years 7 years or more Have you served in the armed forces? Yes No Option 3 Duration: Description Former employer Address of former employer How long were you there? Education Information High school: Highest grade completed 9 10 11 12 College, graduate, post-graduate completed 13 14 15 16 17 18 19 20 21 Major Degree Currently in School? Yes No Where? Area of study Do you have any special skills or licenses? Yes No If yes, please explain/describe. How did you become aware of the CASA program? Are you aware that you will be required to complete training? Yes No Are you willing to participate in ongoing training and court appearances? Yes No List community service organizations or clubs to which you belong: Previous and/or current volunteer activities: Successful completion of 30 hours of initial training is required prior to acceptance into the CASA program. If given advance notice of the training schedule, will you be able to commit to this training?* Yes No Do you have training and/or work experience in any of the following areas? Please check all that apply. Child care Child development Counseling Criminology Drug/alcohol abuse Health care Law Law enforcement Mental health Psychology Public speaking Writing Please brefly describe your experience in these area. For Case Matching and Statistical Purposes Race/ Ethnic Background African American American Indian or Native American Asian Caucasian Hawaiian or Pacific Islander Multiracial Other Decline to state Languages Spoken Are you willing to work with all ages of children? Yes No I prefer ages: 0-5 6-12 13-17 Please be aware that CHILDREN ARE FREQUENTLY MOVED. If you have a preference in the county area where you would be willing to accept a case assignment, you may be required to travel to other areas in the county to maintain contact with the child to whom you are assigned. Would you be willing to travel to maintain contact? Yes No Possibly Background Information Have you been: Arrested for a crime against a child?* Yes No Arrested for a violent felony?* Yes No Arrested for a sex crime?* Yes No Convicted of any crime (excluding vehicle code infractions, but including vehicular misdemeanors or felonies? Disclaimer DUI, misdemeanors, etc ... ) * Yes No Please note - drug/substance (DUI/DWI) violations: Violations under 5 years are reason for exclusion from serving as a CASA volunteer due to Program Policy and Insurance requirements. Are you currently undergoing prosecution for any crime (excluding vehicle code infraction, but including vehicular misdemeanors and felonies)?* Yes No Have you ever been arrested convicted of a crime not mentioned above?* Yes No Are you, or have you ever been, the sibling, household member, parent, significant other or spouse of a child who has been the subject of a report to a Child Protective Agency?* Yes No Are you, or have you ever been, the sibling, household member, parent, significant other or spouse of a child who has been an adjudicated dependent of any juvenile court?* Yes No Are you, or have you ever been, the sibling, household member, parent, significant other or spouse of a child who has been placed under informal supervision in any county's children Social Service Agency?* Yes No Are you currently paid or reimbursed to provide a service to children and/or parents within the Child Welfare and/or Juvernile Court System?* Yes No Have you had a personal experience involving (check all that apply) Child Welfare Foster Care Juvenile Court Other agencies offering services to a child If you answered yes to any of the above background questions, please explain. Would you be interested in helping with other areas of CASA work? (Please check all that apply) Advocate panels Fundraising Office work Public Speaking Publicity Special events Training References Please list three (3) personal references. One must be employer or co-worker if employed. Teachers, ministers, volunteer supervisors or similar may be used in place of employer if unemployed. Please do not list relatives. All references will be mailed a questionnaire to complete. Application approval is pending receipt of at least three returned references. Name* Reference Email Address Does not have email no email Relationship (how this person knows you) Address City State Zip Phone number ________________________________________________________________________________ Name* Referrence E-mail Address Does not have email No email Relationship (how this person knows you) Address City State Zip Phone number _______________________________________________________________________________ Name* Referrence E-mail Address Does not have email No email Address City State Zip Phone number Relationship (how this person knows you) Submit After submitting your application, be sure to RSVP for an info session with a CASA staff member. I certify that the above information is true and correct to the best of my knowledge and belief. I understand and agree that any false statement or omission of material fact will cause my immediate and unconditional dismissal from the Court Appointed Special Advocate program. 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