ࡱ> tvs5@ ;bjbj22 DrXX3K<<<<,,,8,,=p-p-(---///<<<<<<<$=R@p<3W/@/33<<<--<b7b7b73(<8--<b73<b7db78:ht%;-d- w9,4;a;4<0=;@4@ %;<<<<@%;</o0b7 1|1a///<<(,5, VOLUNTEER APPLICATION FORM Instructions: Please read the application carefully and complete all the sections of the form thoroughly. This information is used for screening purposes and must be provided for your application to be considered. All information provided is confidential. Name: ____________________________________________ Date: _______________________________________ Address: __________________________________________________________________________________________ Zip Code: ________________ Home Phone: _________________ Work Phone: ________________________________ Fax: ___________________ Email: ________________________ Gender: ________________________________ Social Security Number: _______________ Date of Birth: _____________ Marital Status:*_______________________ Race/Ethnicity:* ___African American ___Latino ___Asian American ___Native American ___Caucasian ___Bi-Racial: ______________________ If not listed, please specify: ____________________________________ *Optional; answers are used for statistical purposes. Emergency Contact Name: ________________________________________________________________________ Phone: __________________________ Relationship: ____________________________ Employment Status: [ ] Full Time [ ] Part Time [ ] Retired [ ] Student [ ] Other: ____________________________ If Employed (please attach a copy of your resume or list your work history on a separate sheet): Current Job Title: ______________________________ Occupation: __________________________________ Employer Name & Address: ____________________________________________________________________ Days/Hours of Work: ____________________________________________________________ May we add your employer to our mailing list? [ ] Yes [ ] No If yes, Contacts Name & Title: _________________________________________________________________ How did you find out about CASA? ____________________________________________________________________ REFERENCES* Please list three non-related references, both personal and professional (for example: teacher, friend, co-worker, or employer): Name: ______________________________________ Relationship: ________________________________________ Home Phone: _________________________________ Work Phone: ________________________________________ Address: __________________________________________________________________________________________ Name: _______________________________________ Relationship: ________________________________________ Home Phone: _________________________________ Work Phone: ________________________________________ Address: __________________________________________________________________________________________ Name: _______________________________________ Relationship: ________________________________________ Home Phone: __________________________________ Work Phone: ________________________________________ Address: __________________________________________________________________________________________ *If you are invited to training, please inform your references that they will be contacted. Education Please fill in the table below, beginning with the name, location, etc. of the high school you attended and ending with the most recent school you attended. Name of SchoolLocation of School (City, State)Degree(s) ReceivedDate Received Additional training or education (please describe): _________________________________________________________ ACTIVITIES, INTERESTS, AND SKILLS List any community service organizations, social or fraternal organizations, and clubs you have belonged to: (check in the brackets if presently a member) Name Purpose/Activities of Organization _______________________________ ________________________________________________________ [ ] _______________________________ ________________________________________________________ [ ] _______________________________ ________________________________________________________ [ ] Fluent in any language other than English (please list): _____________________________________________________ List your hobbies of special interests: ___________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please describe your past volunteer work experience, hobbies, interests, and/or life experiences that enhance your ability to advocate for children. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Briefly, list any experiences you have in the following areas: Child Welfare: _____________________________________________________________________________________ Juvenile Court System: _______________________________________________________________________________ Foster Care: _______________________________________________________________________________________ What are the strengths that you will bring to this program? __________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Availability Are you able to make the required commitment to serving a child? (1 year) ________________ How many hours per month are you available to volunteer? _________________ Will you be able to attend all of the pre-service training? ____________________ Will you be able to attend in-service training held on the second Wednesday evening of every month? _______________ Are you willing to travel outside of Prince Georges County to visit the child and/or family? _________________________________ Do you have a car available for your use? [ ] Yes [ ] No Are you willing to transport the child(ren)? [ ] Yes [ ] No Drivers License Number: ________________________ State of Issue: __________________ Expiration Date: _______ Other Please list any other names you have used (maiden name, previous marriage, nickname, etc.) _______________________ Please list all states where you have resided as an adult: _____________________________________________________ Please list members of your family/household, their age and relationship to you. Please indicate if they do or do not live with you. Name Age/DOB Relationship Y/N (Live with you) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you ever been convicted of a crime in this or any other state? [ ] Yes [ ] No If yes, please explain: _________________________________________________________________________ ___________________________________________________________________________________________ Has your application to a volunteer program ever been rejected? [ ] Yes [ ] No If yes, please explain: _________________________________________________________________________ ___________________________________________________________________________________________ Have you ever been asked to leave a volunteer program? [ ] Yes [ ] No If yes, please explain: _________________________________________________________________________ ___________________________________________________________________________________________ Due to the serious nature of the job you will be asked to perform, working directly with children and families who are emotionally fragile, and for the protection of both the children and the volunteer, we ask the following questions to help us in making the most suitable match between our volunteers and the children we serve. [ ] Please check here if you would prefer that we address the next two questions in your initial interview. Have you or any members of your family ever experienced any of the following: A. Sexual Abuse [ ] Yes [ ] No If yes, please describe: _________________________________ _____________________________________________________________________________________ B. Substance [ ] Yes [ ] No If yes, please describe: _________________________________ _____________________________________________________________________________________ C. Physical Abuse/Neglect [ ] Yes [ ] No If yes, please describe: ___________________________ _____________________________________________________________________________________ D. Domestic Violence [ ] Yes [ ] No If yes, please describe: ___________________________ _____________________________________________________________________________________ Have you or any members of your family ever participated in counseling or treatment to address: A. Sexual Abuse [ ] Yes [ ] No If yes, please describe: _________________________________ _____________________________________________________________________________________ B. Substance Abuse [ ] Yes [ ] No If yes, please describe: ___________________________ _____________________________________________________________________________________ C. Physical Abuse/Neglect [ ] Yes [ ] No If yes, please describe: ____________________ _____________________________________________________________________________________ D. Domestic Violence [ ] Yes [ ] No If yes, please describe: ___________________________ _____________________________________________________________________________________ Briefly explain what led to your decision to apply to become a CASA Advocate. What attracted you to this particular program? How do you expect to benefit from this volunteer experience? _________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ My signature below signifies that I have read and understand the following statements: I certify that all the information provided on this application is true and accurate. If the information is found inaccurate, I may be released from my duties as a Court Appointed Special Advocate. I understand that my completed application becomes the property of the Court Appointed Special Advocate Program of Prince Georges County. I understand the sensitive nature of this work and, therefore, I give my consent to the CASA Program to make the following inquiries about my background to help determine my suitability as a Court Appointed Special Advocate. FBI/Criminal Background Check Driving Record Check Child Abuse Registry Clerk Reference Checks (3) I agree to follow the policies and guidelines of the Court Appointed Special Advocate Program of Prince Georges County, Maryland, particularly with respect to protecting the confidentiality of the children and families with whom I will be working. Criteria used in the selection of volunteers will be used solely to insure that the individual is able to meet the responsibilities of a CASA. No individual will be rejected because of race, color, religion, creed, national origin, gender, age (if 21 or older), or marital status. ____________________________________________________ _______________________________________ Signature of CASA Volunteer Applicant Date Please return this application to: CASA, Prince Georges County 6525 Belcrest Road, Suite 211 Hyattsville, Maryland 20782 Although applications are accepted any time, to be considered for the upcoming training, PLEASE RETURN BY: _______________________ PAGE 6 PAGE 4 COURT APPOINTED SPECIAL ADVOCATE (CASA) OF PRINCE GEORGES COUNTY "#/" # $    E ) / ./> ,-A| !!! !!!"$"@"L"\"d"""L##ְֵֿֿֿֿֿ֛֛֖֡֡֍h h5CJ h55 hrCJ hX?CJh55>*CJ h5>*h h5>*CJ h CJh h5CJ h55CJ h5CJh55>*CJh5jh5UmHnHujh5U7"## $ U V ( ) [  D E ^` !;;; u v =?56]^)*]^()./>_r$If $$Ifa$$Iflffff$Ifkd$$Ifl\$Z  04 lalffff$Ifkd$$Ifl\$Z  04 lalffff$Ifkd|$$Ifl\$Z  04 lalffff$Ifkd:$$Ifl\$Z  04 lalffff$Ifkd$$Ifl\$Z  04 la  ,-Vljjjhjfjjjjkd$$Ifl\$Z  04 la VWXYST./Z[\ij@A lmn{|# $ u v w l!m!!!!["\"]"^"d"e""""K#L###$$ $ $m$n$$$5%6%%&d (d P R  &d P ##########$((00%1)181=1F244458H:;;;;;;;;;;;;;;;;;;;;򻵻hX?hX?0JmHnHuh50JmHnHu h50Jjh50JU h5CJ h55CJ h55h 5>*CJ h5>*CJ h CJ h5>* h5CJh5h ,%%%%%[&\&&&''s't'''((((()*******H+I+h^h hh^h`h & FI++++,,Y,Z,[,,,--$------E.F...../ & Fh`h` hh^h`hh^h/\/]////00m0n0o000&1'1(1)111F2G222"3#33 !h`h`h^h hh^h`h3333l4m4444354566g7h777777889999 & F h!^ & F h!^ !99H:w:x:y:::::Y;Z;;;;;;;;;;;;;;;;h]h&`#$ !;;;;; ! &P/ =!"#$%n 6Hub`>PNG  IHDREFgAMAPLTE """)))UUUMMMBBB999|PP֭3f333f3333f3ffffff3f̙3ff333f333333333f33333333f33f3ff3f3f3f3333f33̙33333f333333f3333f3ffffff3f33ff3f3f3f3fff3ffffffffff3ffff̙fff3fffff3fff333f3f3ff3ff33f̙̙3̙ff̙̙̙3f̙3f̙333f3̙333f3ffffff3f̙̙3f̙3f3f333f3333f3fff̙fff3f̙3f3f̙fffffffff!___www˲𠠤X"NIDATxu* Eid2EЌꡱ<#!w,[Y 6V:yЏJ`sh^va`r|4'gfxVY%0^1*? 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