ࡱ> %` 23bjbj"x"x 8n@@*W.>.>.>8f>>\PZ?Z?"|?|?|? @ @ @P!P!P!P!P!P!P$QhSEPG @ @GGEP|?|?ZPNNNGv|?|?PNGPNNN|?N? a $X.>HRN PpP0PNvTgK:vTNvTN  @R_BNDT[ED @ @ @EPEPN^ @ @ @PGGGG!J&J&  Contact Information: Last name _______________________ First name ____________________ Middle _____________ Names previously known by: ___________________________________________________________ Street address________________________________________________________________________ City ___________________________________ State _________________ ZIP code _____________ County __________________________________ Home phone _______________________________ Mobile phone _________________________ E-mail address ________________________________ Emergency contact name _______________________ Emergency phone _____________________ Employment: Employment status: ____ full time ____ part time ____ student ____ not employed ____ retired (check one) Employer ________________________________________ Position ___________________________ Street address________________________________________________________________________ City ___________________________________ State _________________ ZIP code _____________ Name of supervisor _____________________________ Work phone _________________________ May we contact your supervisor as a reference? ____ Yes ____ No Demographics: Gender: _____ Female _____ Male Date of birth__________________________________ (check one) Ethnicity: ____ African-American ____ Asian-American ____ Caucasian ____ Latino (check applicable) ____ Native American ____ Unknown ____ other:__________________________________ What is your primary language? ____ English ____ Spanish ____ French ____ Signing (check one) ____ Other:_____________________________________________ Do you speak another/secondary language? ____ English ____ Spanish ____ French (check applicable) ____ Signing ____ other:_______________________________ Formal education (highest year of school completed) ____ some high school ____ GED (check one) ____ high school ____ some college ____ college ____ post-graduate ____ other field of study:_________________________________________ Life History, Experiences and Interests: How long have you been a resident of Fayette County? ___________ Kentucky?____________ If you have lived in the state of Kentucky for less than five years, please provide us with the complete address of your last residence outside of Kentucky: Street address________________________________________________________________________ City ___________________________________ State _________________ ZIP code _____________ How long have you been employed at your current job?__________________________________ Does your employer support volunteer work that will require absence from work?__________ Other than your current employer, have you worked elsewhere in the last five years? ______ If yes, please list your job history of the last five years with dates in the space below: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you served in the military? ____ Yes ____ No (check one) If yes, which branch? ________________________________ Do you have a valid drivers license? ____ Yes ____ No (check one) Drivers license number: ___________________ Car insurance company ____________________ Do you have regular access to a vehicle? ____ Yes ____ No (check one) Have you ever applied to volunteer or have you ever served as a volunteer with another CASA/GAL program before? (check one) ____ Yes ____ No If yes, please list the name(s) of the program(s) in the space below: _____________________________________________________________________________________ _____________________________________________________________________________________ May we contact the(se) organization(s) for reference(s)? ____ Yes ____ No Please list any skills or interests:_______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever had personal experience involving child welfare, foster care, adoption, or juvenile services? If yes, please explain:_________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever been involved in an investigation with the Cabinet for Health and Family Services? If yes, please explain:_________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Can you think of any reason why a judge might be reluctant for you to serve as a CASA volunteer? If yes, please explain:_________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please briefly describe your current volunteer activities:_________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Are you willing to commit five to ten hours per month volunteering with a case should you be assigned as a CASA Volunteer? (check one) ____ Yes ____ No Are you willing to commit to a case that will require your volunteer work for at least one year? (check one) ____ Yes ____ No Do you have any physical or mental condition which would interfere with any essential element of your duties as a volunteer? If yes, please explain: ________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Character References: Please list four character references that have known you for at least two years and are NOT related to you by blood or marriage. Complete addresses are REQUIRED. 1. Full name __________________________________ Phone ____________________________ Street Address _________________________________________________________________ City _____________________________ State ___________________ ZIP Code __________ What is your relationship with this person?_______________________________________ How long have you known this person? __________________________________________ 2. Full name __________________________________ Phone ____________________________ Street Address _________________________________________________________________ City _____________________________ State ___________________ ZIP Code __________ What is your relationship with this person?_______________________________________ How long have you known this person? __________________________________________ 3. Full name __________________________________ Phone ____________________________ Street Address _________________________________________________________________ City _____________________________ State ___________________ ZIP Code __________ What is your relationship with this person?_______________________________________ How long have you known this person? __________________________________________ 4. Full name __________________________________ Phone ____________________________ Street Address _________________________________________________________________ City _____________________________ State ___________________ ZIP Code __________ What is your relationship with this person?_______________________________________ How long have you known this person? __________________________________________ Continued on the next page Please read the following statement before signing: I hereby certify that all information on this application is true and correct to the best of my knowledge. My signature below authorizes CASA of Lexington to make necessary checks to determine suitability to serve as a CASA Volunteer. This may include, but is not limited to, character reference checks, child abuse/neglect records, criminal records, sex offender registry checks and other individuals or agencies that may have knowledge of the applicant. These checks will be conducted before service begins and periodically for the duration of the volunteers service. All information collected will be held in the strict confidence. I understand that the program reserves the right to reject this application for any reason; and that any convictions or pending charges involving a sex offense, child abuse/neglect or related acts that in the programs judgment would pose a risk to children or the programs credibility, will result in the rejection of my application. _______________________________________________ Date ________________________________ (Applicants Signature) This section to be completed by CASA personnel only: CAN Registry: __________ Sent __________ Received AOC Records: __________ Sent __________ Received National Criminal Records/Sex Offender Registry: __________ Sent __________ Received Character References: __________ Sent Received: 1. __________ 2. __________ 3. __________ 4. __________ Interview held: ____________________ by _______________________________ (date) Training completed: ____________________ Oath taken: ______________________ (date) (date) Application reviewed and certified complete by: _________________________________ (signature of CASA personnel) CASA of Lexington is committed to a policy of providing volunteer opportunities to all qualified people regardless of economic or social status and will not discriminate on the basis of race, color, ethic origin, national origin, creed, religion, political belief, sex, sexual orientation, marital status or age. CASA of Lexington is an equal opportunity agency. We encourage applications from women, minorities, and all interested and qualified people.      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