Applicant Information

Name

First Name

Last Name

Date of Birth

YYYY

Primary Phone Number

(###)

###

####

Work Phone

(###)

###

####

May we call you at work?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address, if different

County

Do you have access to a vehicle

Driver's License Number

Are you a citizen of the United States?

Lawful permanent resident?

Are you affiliated in any way with the military?

If yes, please explain.

Work/Volunteer History

Present Employer/Volunteer Supervisor

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Job Title

Dates of Employment

Previous Employer/Volunteer Supervisor

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Employer/Volunteer Supervisor

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Education/Training

Highest Level of Education Completed

Other Educational/Training Programs Completed

If yes to any of the above, please describe.

Legal History

Note: It is important that you be thorough and honest in giving of these answers. Answers which are found to be untrue may disqualify you as a potential volunteer.

Have you ever been arrested and/or charged with a crime?

Yes

Have you ever been convicted of a crime?

Yes

Have you ever been placed on a diversion?

Yes

Have you ever had a conviction, adult or juvenile, expunged from your record?

Yes

Have you ever been involved in a juvenile case as an adult or a child?

Yes

Have you ever been the subject of a child abuse/neglect investigation?

Yes

Do you have any experience with child abuse/neglect?

Yes

If you answered YES to any questions, please explain:

Emergency Contact

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Work Phone

(###)

###

####

Personal References

Please print names, addresses, and phone numbers of people who have known you for at least two (2) years, who know you well, can address how you relate to children and others, and how well you could fulfill the responsibilities of a CASA. The CASA program staff will contact the references you list. DO NOT INCLUDE RELATIVES.

Name

First Name

Last Name

Relationship/Length of Acquaintance

Daytime Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Relationship/Length of Acquaintance

Daytime Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Relationship/Length of Acquaintance

Daytime Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Notice of Screening Procedures

In order to protect children and provide the court with qualified volunteers, a fingerprint-based national criminal history record investigation will be conducted on every applicant, as well as screening through the Department for Children and Families (DCF) Child Abuse and Neglect Central Registry. The Office of Judicial Administration will submit the applicant’s fingerprints to Kansas Bureau of Investigation (KBI) for a Criminal History Record Inquiry. The KBI will provide a report on the applicant’s criminal record investigation to the Office of Judicial Administration. Applicants found to have been convicted of, or charges pending for, a felony or misdemeanor involving sex offense, child abuse or neglect, or related acts that would pose risks to children or the CASA program’s credibility will not be approved for service. Applicants who do not provide fingerprints for criminal history background checks will not be approved to serve as a CASA. The applicant’s local CASA program will make inquires to the Department for Children and Families (DCF) Child Abuse and Neglect Central Registry and registries of other states where the applicant has lived in the past five years. If it is found that DCF or a similar agency in another state lists the applicant as the perpetrator of an act of child abuse or neglect the CASA program will generally disallow certification. All information will be held in strict confidence. Criteria used in the selection of a volunteer will be such as to ensure that the individual is able to meet the responsibilities of a CASA. NO INDIVIDUAL WILL BE REJECTED BECAUSE OF RACE, COLOR, RELIGIOUS CREED, NATIONAL ORIGIN, ANCESTORY, GENDER, AGE, DISABILITY OR MARITAL STATUS. I have read and agree to the above and certify that the information contained in the CASA Volunteer Application is correct and accurate to the best of my knowledge.

Date

YYYY

Kansas CASA Volunteer Application

Spirit of the Plains, CASA, Inc.

Advocating for children in Finney, Greeley, Kearny, Hamilton, Scott, & Wichita counties.