Clinton CASA Volunteer Application

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Please fill out the application completely and we will be in contact shortly over your application. Be advised that Clinton County CASA is dedicated to diversity, inclusion and equity. We value each persons' unique background, expertise and experience and strive to create a volunteer base that affirms and is representative of the children we serve. Please note, all demographics questions are used for the sole purpose of ensuring that we are aware of who we haven't reached yet.

Want a crash course on being a CASA volunteer for Clinton County CASA first?

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Email *

Formal Name *

Nametag/Preferred Name

Phone Number (include area code) *

Are you at least 21 years old? *

Yes

Required

What is your date of birth? *

YYYY

Are you a U.S citizen? *

Yes

Required

What is your race/ethnicity(ies)? Click all that apply *

American Indian/ Alaska Native

Asian or Asian American

Black/ African American

Hispanic, Latinx

Native Hawaiian

White/ Caucasian

Another option not listed here

I prefer not to answer this question

Required

Please indicate your gender(s). Select all that apply. *

Female

Male

Non-binary

Another option not listed here

I prefer not to answer this question

Required

Home Address *

How long have you been at current address? *

Previous Addresses (list all on the last 7 years)

Please list the formal names of those who live in your household and their relationship to you. *

Emergency Contact (please list their name, relationship to you, address, and phone number) *

Current Employment Status: *

Full-time

Part time

Not employed

Retired

Full-time student

Part-time student

Name of Employer and Address

Highest Level of Education: Name of school, Degree completed, major/field of study *

Any volunteer or job related experience dealing with youth, juvenile justice system, etc. ? *

Are you presently a volunteer in any capacity? If yes, indicate position, agency, amount of hours committed monthly. *

List any specific skills/qualifications that you have that would be of value to CASA. *

How did you learn about the CASA program? *

person

facebook

website

other CASA program

Other:

Required

Have you ever applied/or were you ever a CASA volunteer? *

Yes

If yes, where?

Do you have any current or prior history with any Child Protective Service Agency? *

Yes

If yes, explain?

Do you have any past experiences, personally or professionally, with JFS or any juvenile court system? *

Yes

If yes, explain?

Do you speak a second language? *

Yes

If so, which one?

Do you have a valid driver's license? *

Yes

Do you carry active car insurance? *

Yes

Car insurance company name

Have you ever been convicted of a crime in a court of law? *

Yes

If yes, explain?

Please write a short summary about your interest in volunteering, how you hope to benefit from the volunteer experience and explain why you hope to volunteer your time with Clinton County CASA? *

References

Please provide name, phone and email of three references for you. Please alert your references that we will be in contact with them. References should not be family members.

Reference #1 Name *

Reference #1 Phone Number *

Reference #1 Email *

Reference #1 Relationship to you *

Reference #1 How long have you known them? *

Reference #2 Name *

Reference #2 Phone *

Reference #2 Email *

Reference #2 Relationship to you *

Reference #2 How long have you known them? *

Reference #3 Name *

Reference #3 Phone *

Reference #3 Email *

Reference #3 Relationship to you *

Reference #3 How long have you known them? *

Submission

You understand that by submitting this application, you are granting us permission to request information from and share information with other CASA/GAL Programs. You are also acknowledging that you understand that all information on this application will be verified by Clinton CASA to decide your suitability to serve as a CASA/GAL Volunteer—including, but not limited to, employment; past criminal history; involvement with Child Protective Services or the Juvenile Court; previous CASA contacts, and current volunteer activity.

By submitting this application, you certify that you are aware that there may be some circumstances that may not allow you to be eligible to participate in the program at this time including but not limited to nature and disposition of certain criminal offenses; certain types of involvement with Child Protective Services and current and recent matters being heard in the Juvenile Court.

The CASA program will reject any applicant found to have been convicted or, 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

By submitting this application, you certify that the information contained in this application is true and accurate to the best of your knowledge.

A copy of your responses will be emailed to the address you provided.

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