CASA Volunteer Application

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CASA Volunteer Application

 

 

CASA of Clark County                                            

P.O. Box 987

Arkadelphia, AR  71923

870.230.1450                                                                                 

 

 

 

Date: _____________________

 

First Name:_________________________________ Last Name:___________________________________

 

Are you known by any other names? ________________________________________________________

 

Home address:____________________________________________________________________________

 

City, State, Zip: ___________________________________________________________________________

 

Home phone: ______________________________ Cell phone:____________________________________

 

Work phone:_______________________________ Fax # : ________________________________________

 

Email Address: ___________________________________________________________________________

 

Social Security # ____________________________ Driver’s License # ____________________State _____

 

Date of Birth _____________________ Place of Birth ___________________________ Sex: M  F

 

Current Marital/Family Status

 

Single ______________________________  Committed Relationship ______________

 

Married _____________________________ Date ________________________________

 

Widowed ____________________________ Date ________________________________

 

Divorced ____________________________ Date ________________________________

 

Seperated ____________________________ Date ________________________________

 

Spouse’s/Partner’s Name: _________________________________________ Date of Birth ____________

 

Spouse’s employment and position __________________________________________________________

 

 

 

 

Children’s Names                                                                                                                Lives with you?

 

____________________________________________ DOB___________________        Yes      No

 

____________________________________________ DOB___________________        Yes      No

 

____________________________________________ DOB___________________        Yes      No

 

____________________________________________ DOB___________________        Yes      No

 

____________________________________________ DOB___________________        Yes      No

 

 

Education

 

Circle hightest completed:

 

High School: 9   10   11   12             College:   1   2   3   4             Graduate:   1   2   3   4

 

Major _________________________________       Degree ________________________________________

 

Currently enrolled in school? ___________ Part or Full time?___________ Exp. Grad date? __________

 

 

Employment History

 

Name of Company & Phone

 

 

Position

 

 

Supervisor

Employment Dates

To/From

 

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Employment Status:

 

____ Full time

 

____ Part time (hours per week_____ )

 

____ Retired

 

____ Other                                                                                                                   

Personal

List any community groups in which you are presently active (professional associations, faith communities, service organizations, etc.) ____________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Do you have any experience working with children? ______ Yes ______ No

If yes, give organization names and details ___________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Do you give CASA of Clark County permission to obtain information from these organizations regarding your membership?  ______ Yes ______ No

If no, please explain _______________________________________________________________________

Have you or your family had personal/professional experience with:   (if yes, explain)

Child Abuse ___Yes ___No  ________________________________________________________________

Foster Care ___Yes ___No  _________________________________________________________________

Juvenile Court System ___Yes ___No  _______________________________________________________

 

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