Sioux Falls Area CASA Program

Volunteer Application

Volunteer First Name:

Middle Name:

Last Name:

Home Address, City, State, Zip, County (physical address):

Mailing Address (if different from physical address):

Home Telephone Number:

Work Telephone Number:

Cellular/Mobile Phone Number:

Email Address:

Social Security Number:

Gender:

• Male
• Female

Date of Birth:

Employment Status:

• Full-time
• Part-time
• Student
• Not Employed
• Retired

Place of Employment (if applicable):

Employment Position (if applicable):

Emergency Contact Person:

Emergeny Contact Person's Phone Number:

Ethnicity (check all that apply):

• African-American
• Hispanic
• Caucasian
• Native American
• Other
• Unknown

If checked other for Ethnicity please explain:

Formal Education (highest degree of school completed):

• Some high school
• GED
• High School
• Some College
• College
• Post-graduate
• Other

If other selected for formal education please explain:

What is your primary language:

• English
• Signing
• Spanish
• French
• Other

If other selected for primary language please explain:

Do you speak another/secondary language:

• English
• Signing
• Spanish
• French
• Other
• None

If other selected for secondary language please explain:

Can you think of any reason why a judge might be reluctant for you to serve as a CASA Volunteer?:

• Yes
• No

If YES to above question please explain:

Have you ever been accused or convicted of a crime? (An applicant having a charge or conviction for a crime involving a sex offense or child abuse or neglect is disqualified as a CASA Volunteer. Applicants with other midemeanor or felony charges or convictions that would not pose a risk to children or negatively impact the credibility of the CASA Program will be considered on a case by case basis considering the time passed since the incident and the level of rehabilitation):

• Yes
• No

If YES to above question please explain:

Have you ever entered a treatment program relating to admitted incidents of child physical, emotional or sexual abuse that was COMMITTED by you?:

• Yes
• No

Have you ever been investigated by the Department of Social Services for abuse and/or neglect?:

• Yes
• No

If YES to above question please explain:

Have you personally experienced abuse or neglect as a child?:

• Yes
• No

If YES to above question, please explain what you have done to recover from it:

Can you make a minimum on-year commitment to volunteer approximately 8 to 12 hours per month:

• Yes
• No

In an essay format please explain why you are interested in being a CASA Volunteer and describe what you see as the benefits for both yourself and the children? We suggest this essay be no less than 100 words:

Your typed name below serves as your electronic signature (if you are invited for an interview you will be asked to initial this electronic signature):

Today's Date:

ex. mm/dd/yyyy