Application 7th District Serving: Douglas County : District Volunteer Application : Kansas CASA Association

Notice of Screening Procedures

In order to protect children and provide the court with qualified volunteers, a fingerprint-based national criminal history record investigation will be conducted on every applicant, as well as screening through the Department for Children & Family (DCF) Child Abuse and Neglect Central Registry.

The Office of Judicial Administration will submit the applicant's fingerprints to Kansas Bureau of Investigation (KBI) for a Criminal History Record Inquiry. The KBI will provide a report on the applicant's criminal record investigation to the Office of Judicial Administration. Applicants found to have been convicted of, or charges pending for, a felony or misdemeanor involving sex offense, child abuse or neglect, or related acts that would pose risks to children or the CASA program's credibility will not be approved for service. Applicants who do not provide fingerprints for criminal history background checks will not be approved to serve as a CASA.

The applicant's local CASA program will make inquires to the DCF Child Abuse and Neglect Central Registry and registries of other states where the applicant has lived in the past five years. If it is found that DCF or a similar agency in another state lists the applicant as the perpetrator of an act of child abuse or neglect the CASA program will generally disallow certification.

All information will be held in strict confidence. Criteria used in the selection of a volunteer will be such as to ensure that the individual is able to meet the responsibilities of a CASA. NO INDIVIDUAL WILL BE REJECTED BECAUSE OF RACE, COLOR, RELIGIOUS CREED, NATIONAL ORIGIN, ANCESTORY, GENDER, AGE, DISABILITY OR MARITAL STATUS.

Applicant Information

Full Legal Name

First Name *

Middle

Last Name *

Preferred Name

Date of Birth

Month

Day

Year

Gender (Required)

Race (Required)

Ethnicity (Required)

Social Security Number (Required)

Required for background checks

Cell Phone (Required)

Phone Number(s)

Home Phone

Work Phone

Primary Phone (Required)

May you be called at work? (Required)

Best way to reach you quickly (phone / email / text) (Required)

Current Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Length of time at current address (Required)

Previous Addresses - past 7 years (Required)

List previous addresses for last 7 years, include approximate dates

Current Mailing Address, if different

Email Address (Required)

In some cases, transportation of the child to whom you are assigned may be an important part of your role as a CASA volunteer.

Do you have access to a vehicle? (Required)

Do you have a reliable car you are willing to use to transport children? (Required)

Driver's License Number (Required)

Which state issued your drivers license? (Required)

Auto Insurance Company

Auto Insurance Policy Number

Are you a United States Citizen? (Required)

Lawful Permanent Resident

How did you most recently hear about CASA? (Required)

If you selected "Other" above, please indicate the way you most recently heard about CASA.

Work/Volunteer History

Present Employer/Volunteer Agency

Company/ Organization Name (Required)

Company/Organization Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Company/Organization Phone (Required)

Company/Organization Phone

Company/ Organization Email (Required)

Job Description/Title (Required)

Dates of Employment/Volunteer Work

Start Month

Start Day

Start Year

End Month

End Day

End Year

Previous Employment/Volunteer Agency

Previous Company/ Organization Name

Company/ Organization Name

Company/Organization Address

Country

Address Line 1

City

State/Province

Postal Code

Company/Organization Phone

Company/ Organization Email

Job Description/Title

Dates of Employment/Volunteer Work

Start Month

Start Day

Start Year

End Month

End Day

End Year

Previous Employment/Volunteer Agency

Previous Company/ Organization Name

Company/Organization Address

Country

Address Line 1

City

State/Province

Postal Code

Company/Organization Phone

Company/Organization Email

Job Description/Title

Dates of Employment/Volunteer Work

Start Month

Start Day

Start Year

End Month

End Day

End Year

Previous Employment

If not already listed above, list other employment information for the past seven years (employer, position/occupation, dates, address, phone, reason for leaving)

Education/ Training

Highest Level of Education Completed (Required)

Year High School Degree Earned, if applicable

Name of High School (include City/State) (Required)

Post Secondary Education? (Required)

Area of Study

Post-Secondary Degree Earned and Year, if applicable

Name of College (include City/State)

Other Education/Training Programs Completed

Do you have any experience in a related area?

If yes to any of the above, please describe.

Legal History

Note: It is important that you be thorough and honest in giving these answers. Answers which are found to be untrue may disqualify you as a potential volunteer.

Have you ever been arrested for and/or charged with a crime? (Required)

Have you ever been convicted of a crime? (Required)

Have you ever been placed on a diversion? (Required)

Have you ever had a conviction, adult or juvenile, expunged from your record? (Required)

Have you ever been involved in a juvenile case as an adult or child? (Required)

Have you ever been the subject of a child abuse/neglect investigation? (Required)

Do you have any experience with child abuse/neglect? (Required)

If you answered YES to any questions, please explain.

Why are you interested in volunteering with CASA?

What other volunteer experiences have you had in the last 5 years?

Describe experiences you have had working with children.

Describe experiences you have had involving people with backgrounds different than your own.

Personal References

Please list people who have known you for at least 2 years, know you well, can address your personal and professional capacity to work with children as a volunteer in this program, and have an understanding of how well you could fulfill the responsibilities of a CASA volunteer. At least one of your four references must be from an employment or volunteer experience. The CASA program staff will contact the references you list and ask them to complete a written reference form. Information obtained from references will be kept confidential. DO NOT INCLUDE RELATIVES.

Reference Name (1)

First Name *

Last Name *

Relationship (1) (Required)

Length of Acquaintance (1) (Required)

Daytime Phone (1) (Required)

Address (1)

Country

Address Line 1 *

City *

State/Province *

Postal Code *

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Email Address (1) (Required)

Reference Name (2)

First Name *

Last Name *

Relationship (2) (Required)

Length of Acquaintance (2) (Required)

Daytime Phone (2) (Required)

Address (2)

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email Address (2) (Required)

Reference Name (3)

First Name *

Last Name *

Relationship (3) (Required)

Length of Acquaintance (3) (Required)

Daytime Phone (3) (Required)

Address (3)

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email Address (3) (Required)

Reference Name (4)

First Name *

Last Name *

Relationship (4) (Required)

Length of Acquaintance (4) (Required)

Daytime Phone (4) (Required)

Address (4)

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email Address (4) (Required)

Emergency Contact

First Name *

Last Name *

Relationship (Required)

Emerg. Cont. Phone (Required)

Emergency Contact Email

Emerg Cont Wk Phone

Emergency Contact Address

Country

Address Line 1

City

State/Province

Postal Code