OnlineVolunteerApplication : CASA of Merced County

ONLINE CASA VOLUNTEER APPLICATION

Before you begin the application:

Please read the Affirmation & Release Initial Disclosure (link below).
Be advised that you will need approximately 45 minutes to complete this application.
The application must be completed in one sitting.
Read all questions and instructions thoroughly.
Incomplete applications will not be considered.

By completing the CASA Volunteer Online Application you acknowledge and accept the CASA Affirmation & Release Initial Disclosure

BEGIN APPLICATION:

How did you hear about CASA?

(Check all that apply)

Radio
Television
Friend or Family Reference
Newspaper
Billboard
Social Media
Lawn-stake Signs
Other

If Other, please enter:

Section 1: Personal Information

First Name

Legal First Name

Middle Name

Legal Middle Name, if applicable

Last Name

Legal Last Name

Address

Home Address

Country

Address Line 1

City

State/Province

Postal Code

Mailing Address Same as Home Address?

Address:

If no, please enter mailing address:

Country

Address Line 1

City

State/Province

Postal Code

Home Phone Number

Cell Phone Number

Work Phone Number

May we call you at work?

Email Address

Email Address (If left blank you will not receive an email confirmation of application)

Gender

Male
Female

Date of Birth

Date of Birth (MM/DD/YYYY). Volunteers must be 21 or older.

Place of Birth

Place of Birth (City, State & Country if outside US)

Emergency Contact (Name/Relationship)

Emergency Contact (First & Last Name, Relationship)

Emergency Contact Phone Number

Ethnicity

Ethnicity, Other:

If Other, please specify below

Merced County Residency

Resident of Merced County for:

Other State Residency

If applicable, please list other states you have lived in.

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Marital Status

Spouse's Name & Occupation

If married, please provide spouse's name & occupation

Children

Please enter the names and ages of your children

Household Members

Please list the names & relation to all other household members not previously mentioned

Personal Transportation?

Personal Transportation Available?

License Plate Number

If yes, please enter license plate number:

CA Drivers Lic #

CA Drivers License Number:

Insurance

Automobile Insurance Carrier:

Languages

Other Languages

If Other, enter below:

Section 2: Employment & Volunteer Experience

Employment Status

Current employment status

Full-Time
Part-Time
Self-Employed
Student
Unemployed
Retired

Please enter your 3 most recent Employment or Volunteer positions, beginning with current or most recent experience.

1. Company & Job Title

1. Company/Organization & Job Title

1. Employment/Service Dates

1. Dates of Employment/Volunteer Service

Address

1. Company/Organization Address

Country

Address Line 1

City

State/Province

Postal Code

1. Company Phone Number

1. Company/Organization Phone Number

1. Experience type

Paid Position
Volunteer (unpaid) Position

1. Reason for Leaving

Enter next most recent experience

2. Company & Job Title

2. Company/Organization & Job Title

2. Employment/Service Dates

2. Dates of Employment/Volunteer Service

Address

2. Company/Organization Address

Country

Address Line 1

City

State/Province

Postal Code

2. Company Phone Number

2. Company/Organization Phone Number

2. Experience type

Paid Position
Volunteer (unpaid) Position

2. Reason for Leaving

Enter next most recent experience

3. Company & Job Title

3. Company/Organization & Job Title

3. Employment/Service Dates

3. Dates of Employment/Volunteer Service

Address

3. Company/Organization Address

Country

Address Line 1

City

State/Province

Postal Code

3. Company Phone Number

3. Company/Organization Phone Number

3. Experience type

Paid Position
Volunteer (unpaid) Position

3. Reason for Leaving

Please describe duties, responsibilities and likes/dislikes about your past or present employment/volunteer experience(s):

What hobbies, sports, crafts or activities interest you?

Organizations or clubs

Are you a member of any community service organizations or clubs? If so please list them:

Section 3: Education

Education

Please select highest education level completed:

Degrees/Majors

Enter all held degree(s) with corresponding major(s):

Last School & Graduation Date

Last school attended & graduation date:

Are you currently attending school?

Do you have any special skills or licenses? If yes, please list:

Are there any personal, educational or work related constraints that may restrict your availability?

Other Experience

If other, enter below:

Section 4: Personal References

Please list the names, addresses, and telephone numbers of 3 personal or professional NON-RELATIVE references whom we may contact. These references should be able to speak to your character, your reliability and have seen you interact with children.

First Reference

Reference 1

1. First & Last Name

Address

1. Mailing Address

Country

Address Line 1

City

State/Province

Postal Code

Reference 1

1. Phone Number

Reference 1

1. Relationship

Second Reference

Reference 2

2. First & Last Name

Address

2. Mailing Address

Country

Address Line 1

City

State/Province

Postal Code

Reference 2

2. Phone Number

Reference 2

2. Relationship

Third Reference

Reference 3

3. First & Last Name

Address

3. Mailing Address

Country

Address Line 1

City

State/Province

Postal Code

Reference 3

3. Phone Number

Reference 3

3. Relationship

Section 5: Background Information

1. Have you ever been arrested for a crime against a child?

2. Have you ever been arrested for a violent felony?

3. Have you ever been arrested for a sex crime?

If you answered "yes" to 1,2 or 3 above, can you produce a written declaration of a "Finding of Factual Innocence?"

Have you ever been convicted of any crime within the past 5 years?

(excluding vehicle code infractions, but including vehicular misdemeanors or felonies)

Have you ever been arrested or convicted of any crime not mentioned above?

Are you or have you been the subject of or been involved in a reporting to a Child Protective Agency?

Are you or have you been the subject of or been involved in an adjudicated dependent of any juvenile court?

Are you or have you been the subject of or been placed under informal supervision in any county's children's social service agency?

Have you ever been directly involved in a court proceeding in this or any other state?

As a child, were you or any of your siblings ever the subject of a child abuse report?

Are you currently paid or reimbursed to provide a service to children and/or parents within the child welfare and/or Juvenile Court System?

Note: Any applicant found to have been convicted of, or having charges pending for a felony or misdemeanor WILL NOT be accepted as a CASA Volunteer.

Section 6 : Medical Information

Are you currently under the care of a medical professional, and/or therapist and/or taking prescribed medications?

If yes:

If you answered yes, please explain how it will or will not impact your role & duties as a CASA Volunteer:

Section 7 : Other