Application Date of Application: Name: Home Address: Mailing Address (if different) Home Phone Cell Phone Work Phone email How did you hear about CASA? YesNo Date of Birth Do you have a legal right to reside and work in the U.S.? YesNo Marital StatusSingleMarriedMarried but SeparatedDivorcedWidowedOther (describe below) Marital Status Other: Number of Children: Emergency Contact: name: phone: Which position(s) are you interested in? Child AdvocateOffice AssistanceFundraising Are you able and willing to commit to these requirements? Completing 30-40 hours of pre-service training?Completing 12 hours of in-service training each year?Devoting appropriate time to fulfill CASA responsibilities?Devoting a minimum of 1 year to the CASA program?Undergoing a thorough background check?Transporting yourself to fulfill your CASA responsibilities? Do you have a valid driver's license? yesno Do you have a vehicle? yesno Do you have automobile insurance? yesno Education High School (name of school) Location Did you graduate? yesno college (name of school) Location Did you graduate? yesno Degree Post Graduate (name of school) Location Did you graduate? yesno Degree Employment Current Employment Status Not WorkingFull TimePart TimeRetired Current Employer or Last Employer Position Additional Questions: Have you ever been convicted of an offense by a civilian or military court? Exclude minor traffic violations. yesno Are you currently charged with an offense for which you have yet to be tried? Exclude minor traffic violations. yesno Have you ever had prior involvement with DHR or any other state’s child protection agency either personally or professionally? yesno Do you have any case pending in Juvenile or Family Court? yesno Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer? yesno If you answered yes to any of the questions above, please explain.