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Be for the child


If less than 10 years, please provide previous address

For Legally Required Background Check
Ethnicity (for reporting purposes)
Do you have school age children?

In an emergency contact

Do you drive?
Do you have an automobile available to you?

Your Education (check highest completed)

High School
Are you presently enrolled in school?

If yes, name of school and course of study

Name/Address of Last Employer or Project and Description of work.
Include Name, Mailing Address and Relationship
Four References who are not related to you are required.
Areas of interest with CASA:
With advance notice, will your schedule permit you to appear in court on Wednesdays?
Have you had personal/professional experience involving:
Have you ever been accused of child abuse or neglect?
Have you ever been arrested for a crime or convicted of a felony?
Are you currently or previously been in a custody dispute?
Affirmation and Release
By checking the box below, I hereby affirm that all the answers provided are true and correct to the best of my knowledge. I hereby authorize CASA of Campbell County, Inc. to investigate my background to determine my fitness as a potential volunteer. I understand that the information requested in this application will be used only for determining suitability as a CASA volunteer. Further I understand that after the successful completion of my training, I will be expected to serve a minimum of one year in the CASA program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the Executive Director with as much 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 who are directly involved in the case or who will be consulted for their professional knowledge and expertise. Furthermore, pursuant to applicable laws in a state concerning authority to obtain information, I authorize CASA of Campbell County, Inc. to obtain all investigative records for examination for verifying the accuracy of criminal violation information contained on an application to work for CASA; and/or supply a fingerprint sample and submit to a criminal history records check to be conducted by any state. If required for background checks, I agree to provide CASA my social security number as well as a copy of my driver’s license and automobile insurance card. I understand that failure to authorize CASA to complete background checks or provide requested information to complete background checks or if I do not pass background checks, eliminated me from further consideration as a CASA volunteer. I also understand that CASA can reject my application for any reason. CASA of Campbell County will 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 that would pose risks to children or this agency’s program.

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