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Making everlasting change starts with one child at a time.

Personal Information
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Name:
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Address:
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City:
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State:
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Zip:
Phone:
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Occupation:
Spouse's Name (if applicable):
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Emergency Contact:
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Phone:
Ethnicity:
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If so, which ones?

 

 


 

Education
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High School Attended:
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Grade Completed:
College/Trade School:
Years Attended:
Degrees/Training Received, Subjects Studied:

 

 


 

Employment Experience
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Present Employer:
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Phone:
Address:
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Job Title:
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Type of Work:
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How long have you worked at your present job?

 

 


 

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Previous Employer:
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Phone:
Address:
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Job Title:
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Type of Work:
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How long did you work at this job?

 

 


 

 

 

Background Information
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If yes, please explain:
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Are there any criminal charges pending against you at this time?
If yes, please explain:

Please be aware that the CASA program may reject an 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 that would pose risks to children or the CASA program’s credibility.

 

 


 

 

 

PLEASE COMPLETE THE FOLLOWING QUESTIONS:
If so, please describe your work hours and flexibility. (Remember, you may have to visit your children, talk to professionals and visit schools during the weekday.)

 

 


 

Rank Your Skills (1 = Low; 5 = High)
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References

APPLICANT:

PLEASE LIST THREE REFERENCES
: (Furnish complete information) (No family members)

Please include one employer if applicable.

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1. Name:
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Phone:
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Address:
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City:
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State:
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Zip:
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Occupation:
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How long have you known this person?

 

 


 

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2. Name:
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Phone:
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Address:
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City:
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State:
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Zip:
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Occupation:
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How long have you known this person?

 

 


 

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3. Name:
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Phone:
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Address:
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City:
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State:

 

Acceptance into program will not be final until all references are received.


 

State:
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