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CASA GLYNN, INC.

VOLUNTEER APPLICATION
(PLEASE PRINT)

______________________________________________________________________
Name
______________________________________________________________________
Address
______________________________________________________________________
City State Zip

______________ ________________ ________________ ____________________

Home Phone Work Phone Cell Phone Email Address

____________________________________________________________________
Previous Address

Are you employed? 0 Yes 0 No If yes: 0 Full-time 0 Part-time

______________________________________________________________________
Place of Employment Position

May you be called at work? 0 Yes 0 No

Have you ever worked with or for Juvenile Court? 0 Yes 0 No

Do you have a valid Georgia Driver’s License? 0 Yes 0 No

Driver’s License #_____________

Have you lived in another state in the past 5 years? 0 Yes 0 No

If yes, which state? ________

______________________________________________________________________
Date of Birth Marital Status

______________________________________________________________________
Spouse’s Name Occupation Phone Number

Do you have children? 0 Yes 0 No If so, what are their ages? _______________

In case of emergency please call: __________________________________________

Education: (circle highest year completed)

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

______________________________________________________________________
Major Degree
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Do you have any training or experience in any of the following?

0 Medicine 0 Mental Health 0 Counseling

0 Psychology 0 Drug or Alcohol Abuse Programs 0 Child Development
0 Child Care 0 Child Welfare 0 Social Work
0 Education 0 Criminology 0 Law Enforcement
0 News Media 0 Advertising or Public Relations 0 Writing
0 Public Speaking 0 Art or Graphic Design 0 Fundraising

List your community activities and memberships in clubs, religious and professional groups and
other organizations:
____________________________________________________________________________

____________________________________________________________________________

Languages spoken: ___________________________________________________________

Hobbies/Special Interests:_______________________________________________________

Have you sought treatment for or are you currently in treatment for a mental health issue? (A “yes”
does not necessarily disqualify you from the volunteer program.) 0 Yes 0 No
____________________________________________________________________________

Please describe any personal or professional experiences you have had which involved child abuse
or neglect, the Department of Family and Children’s Services, the Juvenile court system, foster
care, or other agencies offering services to children.___________________________________

_____________________________________________________________________________

Have you ever been arrested? 0 Yes 0 No If yes, please explain below. A conviction does
not necessarily disqualify you from the volunteer program. However, CASA will automatically reject
any applicant found to have been convicted of, or having charges pending, for a felony or
misdemeanor involving a sex offense, child abuse or neglect, or related acts what would pose risks
to children or the CASA program’s credibility. _______________________________________

____________________________________________________________________________

Have you ever had a case with or investigation performed by the Department of Family and
Children Services? 0 Yes 0 No If yes, please explain below:

____________________________________________________________________________

____________________________________________________________________________

Are you prepared to complete 35-40 hours of pre-service training; and, 12 hours per year of in-
service training? 0 Yes 0 No

Does your schedule permit you to attend meetings, court hearings or foster care reviews during the
work day? 0 Yes 0 No
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What do you feel are the strengths and weaknesses that you bring to this program?

____________________________________________________________________________

____________________________________________________________________________

REFERENCES: Please list four references of people who know you well, preferably for whom you have
worked in either a paid or volunteer capacity. Letters will be sent, so full addresses are necessary, including
zip code. One reference may be a relative.

Name Relationship ____

Address ____
City State Zip ____
Telephone (H) (W) ____

Name Relationship _____

Address _____
City State Zip _____
Telephone (H) (W) _____

Name Relationship _____

Address _____
City State Zip _____
Telephone (H) (W) _____

Name Relationship _____

Address _____
City State Zip _____
Telephone (H) (W) _____

Write a brief statement on why you have chosen to work with the CASA program at this particular
time in your life. (Use additional paper and submit with application).
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I,_____________________________________, hereby affirm that all of the answers provided on

my volunteer application are true. I hereby authorize CASA Glynn Inc., and any law enforcement
agency they authorize, to investigate my background to determine my fitness as a potential
volunteer.

I further understand that the information requested in this application will be used only for the
purpose of determining my suitability as a CASA volunteer. Further, I understand that completion of
training does not guarantee that I will be assigned a case. If I have successfully completed the
training and have met all other requirements, and it has been determined that I am suitable
volunteer, I understand that I will be expected to serve a minimum of one (1) year in the CASA
program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my
written resignation to the Executive Director of the Advocacy Coordinator with as much advance
notice as possible. I am aware of the sensitive and confidential nature of the official documents,
reports and other material I will examine in my capacity as a CASA volunteer. I will discuss these
matters only with those persons directly involved in the case or who will be consulted for their
professional knowledge and expertise.

I also understand that if for any reason it becomes apparent that my activities are contrary to the
policies, goals and/or philosophy of the CASA program, and their desire to provide quality services
to abused and neglected children, my services as a CASA volunteer will be terminated.

Name (please print)

Signature

Date

CASA Glynn, Inc.

P.O. Box 145
Brunswick, GA 31520
912-264-4448 FAX 912-264-4451
Email: [email protected]
www.casaglynn.org