Volunteer App test

CASA Volunteer Application

I am over 21 years old and have read the information about and want to become a volunteer:*

Yes

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*

Gender

No. of children

Spouse's name

Spouse's occupation

Address

Phone

Do you have auto insurance?

Yes

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*

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

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?

Duration:

Description

Former employer

Address of former employer

How long were you there?

For Case Matching and Statistical Purposes

Race/ Ethnic Background

Languages Spoken

Are you willing to work with all ages of children?

Yes

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

Possibly

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.

Print full name*

________________________________________________________________________________

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