Date*:

Last Name*:

Maiden/AKA (if applicable):

First Name*:

Middle Name:

Street Address*:

Apt. #:

City*:

State*:

Zip*:

Date of Birth*:

Gender*: MF

Ethnicity:

Cell Phone:

Home Phone:

Business Phone:

Email Address*:

Employer:

Job Title:

Full or Part-time: ---Full-timePart-time

Scheduled Hours:

Drivers License Number*:

(Driving is not required in your role as a CASA)

State Issued*:

Expiration Date*:

Car Insurance Carrier:

Policy Number:

Exp/Renewal Date:

Emergency Contact*:

Relationship*:

Contacts Phone*:

Describe any personal or employment constraints that may restrict your time availability:

Previous and/or current volunteer activities:

Educational Background*:

Hobbies/Special Interests*:

Languages Spoken*:

Do you know sign language*? ---YesNo

How did you become aware of this program*?(Please provide as many specifics as possible: ex. name of web site or newspaper, etc.)

Have you attended a CASA Information Session*? ---YesNo

If so, when?

What are the strengths that you bring to the program?

What may be some of your challenges in this role?

How long have you lived in San Francisco?

In California?

Have you ever been arrested*? ---YesNo

If yes, please provide date and details:

Have you had any personal experiences involving (check all that apply):
 Child Abuse Adoption Foster Care Family Court Juvenile Court System No Involvement

If yes, please explain:

Write a brief statement on why you have chosen to work in the CASA Program at this time in your life:

Describe any experiences you have had working with children:

Describe any involvement with the Department of Social Services:

What additional information do you need about the CASA Program?

Are you applying for the Winter, Spring, Summer or Fall training program? WinterSpringSummerFall

Please complete a brief statement regarding your feelings about the issue of child abuse and what you have to offer CASA as a non-violent role model.

Please provide the names and complete mailing addresses for four references. Please include a minimum of two professional references (i.e., supervisors, clergy, teachers, or therapists). We also ask that you choose two local references. Inform the people you list here to expect a reference form from our office. It should not take them more than five minutes to complete. Please advise them that you will not be assigned a child until the reference forms have been returned to our office. We verify all references.

(1) Name*:

Complete Mailing Address*:

City*:

State*:

Zip*:

Phone*:

Email*:

Describe Type and Length of Relationship*:

(2) Name*:

Complete Mailing Address*:

City*:

State*:

Zip*:

Phone*:

Email*:

Describe Type and Length of Relationship*:

(3) Name*:

Complete Mailing Address*:

City*:

State*:

Zip*:

Phone*:

Email*:

Describe Type and Length of Relationship*:

(4) Name*:

Complete Mailing Address*:

City*:

State*:

Zip*:

Phone*:

Email*:

Describe Type and Length of Relationship*:

The information requested in this application and other parts of the background check and selection process will be used only for the purpose of determining suitability as a volunteer, and will be kept in confidence.

BY SUBMITTING THE APPLICATION, I AGREE TO AND/OR AUTHORIZE THE FOLLOWING:

I understand that by submitting this application, I am authorizing inquiries to be made concerning my suitability as a volunteer. The background investigation will include a formal security check. I acknowledge that if I am found to have been convicted of or to have current charges pending for a felony or misdemeanor involving a sex offense, child abuse, or child neglect, I will be ineligible to serve in the role of a CASA.

I authorize SFCASA to interview me in depth regarding my personal background and
experiences. Children in the CASA Program have experienced or witnessed a variety of
personal challenges including emotional, physical or sexual abuse, substance abuse and/or mental illness. Because appropriate assignment of a child depends on the CASA‚'s own experiences of these issues, I understand that my SFCASA interview will include questions about these topics. If I become uncomfortable with these questions I will be free to terminate the interview, but I understand that my application will then be considered withdrawn.

I understand that volunteers are selected based on their individual ability to meet the responsibilities of the CASA Program, as determined in the discretion of SFCASA staff. I also understand that because of the confidential nature of the screening process, this agency is not obligated to disclose to me reasons or sources for any decision concerning my acceptance or non-acceptance into the Program. I understand that all materials I submit become property of SFCASA and will not be returned. Furthermore, I hereby waive any claim that the selection practices and policies described above are an invasion of privacy.

I understand that the agency must take the best interest of the children into consideration first when matching them with a CASA. Thus, I understand that in the event that I should complete the entire CASA training, (1) SFCASA is not obligated to certify me (present me to the Court to be sworn as an officer), (2) SFCASA is not obligated to assign, or to actively seek to assign to me a child, and (3) I am not obligated, if called upon, to perform volunteer services herein applied for. However, no individual will be rejected because of disability, ethnicity, gender, marital status, national origin, race, or sexual orientation.

I understand that I must complete 40 hours of training that includes at least 2 hours observing court proceedings before being considered for certification as a CASA volunteer. I further understand that I must participate in an additional 12 hours of in-service training each year. If selected for program certification and assigned to a child's case, I understand that my duties may include court appearances, visits to homes of family members involved in the case, and possibly visits to institutions or treatment programs.

Finally, I recognize that any changes made to the understandings above must be made in writing and signed either by the Executive Director or the Chair of the Board.