VOLUNTEER APPLICATION FORM
Last name First name Middle
Maiden Name or other names used
Home address Apt.
City State ZIP
Gender : ○Female ○Male Date of birth Social Security number
Home phone Cell phone E-mail Address
Employment status ○Full time ○Part time ○Student ○Not employed ○Retired
Place of employment Work phone
Emergency Contact Emergency phone
Ethnicity ○African-American ○Asian-American ○Caucasian ○Latino ○Native American
○Other ○Bi-racial
Formal education (Highest year of school completed) ○Some high school ○GED
○High school ○Some college ○College graduate ○Post-graduate ○Other
Degree(s) Held
Name of College Address
Other Educational/Training Programs Completed
Primary Language ○English ○Spanish ○Signing ○French ○Other
Do you speak another/secondary language? ○Spanish ○Signing ○Other
Referred by: ○Flyer ○Friend ○Internet ○Local newspaper ○Local radio
○National Media ○NCASAA ○Other ○Unknown ○Volunteer referral agency
Little Dixie CASA does not discriminate in its volunteer recruitment activities based on age, gender, sexual orientation, race, ethnicity, nationality, disability, socio-economic level or religion.
Please list skills and interests:
Please complete the information for three references of people who know you well, other than relatives, preferably for whom you have worked in either a paid or volunteer capacity:
Name Daytime Phone Number
Address City/State/Zip
Relationship Length of Acquaintance
Name Daytime Phone Number
Address City/State/Zip
Relationship Length of Acquaintance
Name Daytime Phone Number
Address City/State/Zip
Relationship Length of Acquaintance
Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer?
Have you ever been accused or convicted of a crime? _____Yes _____No
(An applicant having a charge or conviction for a crime involving a sex offense or child abuse or neglect is disqualified as a CASA volunteer. Applicants with other misdemeanor or felony charges or convictions that would not pose a risk to children or negatively impact the credibility of the CASA Program will be considered on a case by case basis considering the time passed since the incident and the level of rehabilitation.)
If yes, please explain:
Have you ever entered a treatment program relating to admitted incidents of child physical, emotional or sexual abuse that was committed by you? _____Yes _____No
Have you ever been investigated by the Department of Human Services for abuse and/or neglect?
If yes, please explain:
Little Dixie CASA reserves the right to make any background/reference checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All information obtained will be held in the strictest confidence.
Do you consent to a routine criminal background check? _____Yes _____No
Drivers License # and Issuing State______
I acknowledge that the information in this application is true to the best of my knowledge. I understand that falsification of any information in this application or in subsequent interviews during the application process with Little Dixie CASA program could cause denial of participation in the program. Little Dixie CASA reserves the right to reject a potential volunteer due to prior drug, alcohol, or mental health related issues as well as child welfare and/or criminal activity history.
Applicant’s Signature Date
Please return to Little Dixie CASA
603 SW B Street 502 West Duke 312 NW Texas
Antlers, OK 74523 Hugo, OK 74743 Idabel, OK 74745
580-298-2921 580-326-6441 580-286-9348
580-298-3111 FAX 580-326-4841 580-286-3559 FAX
Revised 03/20/08