COURT
“CASA OF LUZERNE COUNTY”
APPOINTED SPECIAL ADVOCATES PROGRAM
VOLUNTEER APPLICATION
The information on this form will help us assess your qualifications to serve as a CASA volunteer. Please read the
directions carefully and complete all sections of the form. Information provided by you is confidential. If your
application is accepted, CASA Program staff will contact you to schedule a personal interview.
Date:
Social Security Number
Phone(Day)
Name:
Date of Birth
Any Previous Names (including Maiden)
Address
City
State
Zip Code
Email Address _________________________________________________________________________________
Is your primary interest to learn more about becoming a CASA volunteer?
o
If your primary interest in the CASA program is not in becoming a volunteer, or
o
You are not 21 years of age or older, or
o
You cannot commit to the time requirements of the program right now, would you be interested in any of
these other areas to support the CASA program?
o
Special Events
o
Office Assistant
Do you have any special talents you would like to share (competence with software programs, media contacts,
enjoyment in decoration, etc.)
Have you lived in Pennsylvania for five years or longer?
If not, where did you come from?
Gender
When?
Name of Spouse/ Significant Other
In case of an emergency, call
Do you drive?
Do you have access to a car?
Do you have any personal health concerns?
Are you currently employed?
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Phone
Car Insurance Co.
If yes, explain:
Employer’s Phone #
Employer’s Name and Company Name:
Address:
City:
State:
Full or Part time?
In What Position?
Retired?
Zip Code:
Previous Employer’s Name:
Education and/or Special Training
Meaningful Volunteer Experiences:
1.
2.
Present Volunteer Activities:
1.
2.
3.
Do you speak any languages other than English?
If yes, which:
How does your spouse / significant other feel about your working with CASA?
How did you become aware of CASA?
As a CASA volunteer, will you be able to participate in on-going training and court appearances?
Have you had an opportunity to discuss CASA with your supervisor?
Can you see yourself visiting with a family in their home, or with an institutionalized child?
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What do you feel are the strengths that you will bring to the program?
1.
2.
3.
What are your primary concerns about becoming a volunteer in the program?
1.
2.
3.
Please describe if you, your family, or friends have had any experience with the following:
1. Child Welfare:
2. Juvenile Court System:
3. Foster Care:
4. Other experiences offering services to a child:
Have you ever been convicted of a crime (misdemeanors and/or felonies)?
If yes, what charge?
Date of Arrest:
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Where?
In the past, have you had a:
PA Child Abuse Clearance
Date:
Request for Criminal Background Check
Date:
Childline Verification
Date:
CASA may reject your application if you are found to have been convicted of, or have 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.
Can you think of any reason why the judge of Dependency Court might be reluctant to appoint you to a case?
Yes/No
If yes, why?
Write a brief statement on why you have chosen to volunteer with CASA at this particular time:
Write a short summary about your interest in volunteering and how you hope to benefit from this volunteer
experience:
Explain what role you believe society should play in protecting the rights of children:
Explain what role you believe society should play in helping a family overcome hardships and remain living
together as one unit:
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Please write a full page autobiography (including hobbies, special interests, and any affiliation that are important to
your values):
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REFERENCES
Important: The CASA office will send information requesting a letter of reference. Please supply the full
address.
1. Name:
Phone:
Relationship:
Address:
City:
2. Name:
State:
Phone:
Zip Code:
Relationship:
Address:
City:
State:
3. Name:
Phone:
Zip Code:
Relationship:
Address:
City:
State:
Zip Code:
TRAINING SCHEDULES:
Please check which schedule you prefer. If neither the Saturday or weeknights fit your
schedule, what would work better to fulfill the 30+ hours of training?
____ Saturday: Five 6-hour sessions
____ Evenings: Ten 3-hour sessions on Tuesday and Thursday
____ Other: ___________________________________________________
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AFFIRMATION AND RELEASE
I,
, hereby affirm that all the answers provided on my volunteer
application are true. I hereby authorize the CASA of Luzerne County Program 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
suitability as a CASA volunteer. Further, I understand that after the successful completion of my 40 hour training, I
will be expected to serve 18-24 months in the CASA program. If unforeseen circumstances prevent me from
fulfilling the obligation, I will submit my written resignation to the program coordinator with as much advanced
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 only discuss these matters with those persons
directly involved in the case or who will be consulted for their professional knowledge and expertise.
YOUR SIGNATURE
TODAY’S DATE
PLEASE RETURN COMPLETED APPLICATION TO:
Marcelle Dotson, M. Div. Advocate Coordinator
Phone: (570) 855-2247
CASA of Luzerne County
Cell: (570) 855-2566
667 North River Street
wwwluzernecasa.org
Plains , PA 18705
Email: [email protected]
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