SEI Voices for Children

* First Name

* Last Name

Maiden/Other Names

* Social Security Number

Email

* Date of Birth

Place of Birth

* Address

* Phone Number

Alternate Number

* Years at Current Address

* Years at Previous Address

* Marital Status

Married

Single

Divorced

Widowed

Separated

Spouse name/ occupation

Children at Home

Name, Sex, Date of Birth

Other Members of the Household

Name, Sex, Date of Birth

* Do you have transportation available to you?

Do you have any health issues that you wish the Voices for Children Program to be aware of and/or will require special accomidations?

List your current community activities and membership in clubs, churches, etc.

* Languages Spoken

Hobbies/Special Interests

How did you hear about the Voices for Children CASA/GAL Program?

* How much time can you contribute weekly as a CASA/GAL volunteer?

* Are you:

Employed Full Time

Employed Part Time

Retired

Student

Between Jobs

If you are enrolled in school, where are you attending?

* Your education (Please select the highest level completed):

Major

Degree(s)

Place of Employment

Position

Work Address

Supervisor Name/Phone Number

Dates of Employment

Name/Address of Next Previous Employer

Next Previous Employer Telephone Number

Description of Duties

Supervisor Name/Phone Number

Dates of Employment

Reason for Leaving

Volunteer Experience: Name/Address of Current Volunteer Project

Telephone

Position

Description of Duties

Supervisor Name/Phone Number

Dates with Project

Name/Address of Previous Volunteer Project

Telephone

Position

Description of Duties

Supervisor Name/Phone Number

Dates with Project

Reason for Leaving

Do you have any training or experience with the following:

Medicine

Psychology

Public Speaking

Education

News Media

Child Welfare

Art/Graphics

Criminology

Writing

Social Work

Counseling

Advertising/Public Relations

Law Enforcement

Drug/Alcohol Problems

If anything in the above question was selected, please describe the training or experience.

* Describe your experience working with children.

* Have you ever been abused or neglected?

* Are you currently involved in any family litigation?

* Have you ever been involved in any litigation that involved a CASA/GAL or any CASA/GAL Program?

* Have you ever been charged with or cited for a crime?

If so, where?

What charge(s)?

Date of Arrest

Date of Disposition

What was your plea?

What was the outcome?

* Have you ever had a permanent injunction for domestic violence entered against you?

If yes, explain

* Have you ever had an allegation or finding of abuse, neglect, or abandonment of a child or an adult entered against you?

If yes, explain

* Can you think of any reason why a judge may be reluctant to have you serve as a CASA/GAL?

If yes, explain

* Are you aware of any current or potential conflict of interest you may have with Voices for Children, Circuit Judges, or the Department of Child Services?

* AFFIRMATION AND RELEASE: All applicants for CASA/GAL are required to authorize the program to perform a national, sate and local criminal records check.

I understand that any applicant who does not agree to the application requirements will be eliminated from further consideration as a CASA/GAL volunteer.

By checking the statements below you understand and agree to all requirements of the CASA/GAL Voices for Children volunteer application process.

* I certify that to the best of my knowledge and belief all statements contained herein and on any attachments are true, correct, and made in good faith.

I agree

* I hereby authorize Voices for Children to investigate my background to determine my fitness as a potential volunteer.

I agree and understand that this consent shall continue to be effective during my tenure as a CASA/GAL volunteer.

* I understand that the Legal Advisor or Program Director of Voices for Children shall have the sole discretion to accept or reject my application.

I agree

* I understand that the information requested in this application will be used for the purpose of determining my suitability as a CASA/GAL volunteer.

I agree and understand that the information that is contained in this application is confidential.

* I understand that after the successful completion of my training, I will be expected to serve minimum of one year in the CASA/GAL.

I agree and if unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the Legal Advisor or Program Director of Voices for Children with as much advance 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/GAL volunteer.

I agree

* I hereby affirm that all of the answers provided on this application are true.

I agree and understand that it is a misdemeanor for any person to willfully, knowingly, or intentionally fail, by false statement, misrepresentation, impersonation, or other fraudulent means, to disclose in any application for a volunteer position

any material fact used in making a determination as to the application's qualification for such position.

* I understand that CASA/GAL volunteers do not provide direct services to the children or family they are assigned to as agents of the Voices for Children program.

I agree and understand that direct services include but are not limited to: driving family members and/or children anywhere, allowing family members and/or children into your home for any period of time, etc.

* Name

* Social Security

* Ethnicity

* Sex

* Date of Birth

* Address

* Driver's License

* Signature

* Date

Volunteer Application