Last Name: 

First Name: 

MI:                             

Other Names Used (maiden, former, or nick names): 

Address: 

City:       

State:      AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:       

Home Phone: 

Work Phone: 

Mobile Phone: 

E-mail Address: 

DOB: 

Place of Birth: 

Social Security Number: 

Race: 

Sex:       Female Male

Married:  Yes     No

If yes, spouse's name: 

If yes, spouse's occupation: 

Children:  Yes     No

Children's Names and Birthdates (Name, dd/mm/yy):

Do any other people live in your house?  Yes     No

If yes, briefly describe their relationship with you:

Please check the highest level of education achieved:

Primary education                                Bachelor Degree

High School Diploma (or equivalent)    Master's Degree

Business/Vocational/Tech                    Doctorate Degree

Associate Degree

Current Employment or School Enrollment:

Brief Employment History:

Do you drive?  Yes     No

Do you have a car available?  Yes     No

Have you had any driving citations in the last 3 years?  Yes     No

Describe your present physical condition:  Good     Fair     Poor

Have you ever been arrested for a felony or first degree misdemeanor?  Yes   No

If yes, what was the disposition of the arrest?

Have you ever been convicted of a felony or first degree misdemeanor?  Yes  No

If yes, what were the charges? 

If convicted, where    and when 

Describe your current community activities and memberships (club, church, fraternal and civic organizations).  Indicate any offices held.

How did you hear about the CAMDEN COUNTY CASA PROGRAM?

 Why would you like to be a CASA VOLUNTEER? 

List four (4) personal references.  Please give complete address with zip code.  (Do not use immediate family members):

Name:     Name: 

Address:    Address: 

Telephone:      Telephone: 

Relationship:         Relationsip: 

Name:     Name: 

Address:    Address: 

Telephone:      Telephone: 

Relationship:         Relationship: 

I have read the foregoing questions carefully and have answered them truthfully and completely.  I hereby agree to have the Camden County CASA Program staff check my personal references, law enforcement files, child abuse registry, and any present or past employment records.  In addition, I agree to inform the CASA Program staff of any grievances or disciplinary actions involving me (whether employment related or otherwise), and past or present mental health or emotional problems (whether or not treatment was sought).  Failure to provide such information and/or authority to investigate shall result in my not being accepted as a CASA Volunteer, or immediate dismissal from the Program.

I understand that after completing the required training and screening process, I will be expected to serve a minimum of one (1) year in the Camden County CASA Program.  If unforseen circumstances should prevent me from fulfilling this obligation, I will submit my written resignation to the Program Director with as much advance notice as possible.

I understand and Agree     Do Not Agree    to the above statements.

Date:    (dd/mm/yy)