CASA of Walker, San Jacinto
& Trinity Counties
1300 11 th Street Suite 430 B
P.O. Box 275
Huntsville, TX 77342
Tel: 936-291-6363
Fax: 936-291-0009
Email: casa@casaofwalkercounty.org
Website: www.casaofwalkercounty.org
Date of Completion: ____________________
Huntsville, TX 77342
Last name: _______________________________ First name: ________________________ M iddle: _______
Gender: Date of birth: ____/____/____
Home address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________ County: ____________________
Phone: (H) (_____) ______-_______ (Cell) (_____) ______-_______
(W) (_____) ______-_______ (Fax) (_____) ______-_______
E-mail address: __________________________________ @ ______________________________
Marital Status: Single Married Divorced Widowed Separated
Spouse’s Name: ___________________________
N/A
Children(s) (name & age) : _______________________________ _______________________________
_______________________________ _______________________________
Employment status : Full time Part time Student Not employed Retired
Place of Employment: ________________________________________________________________
Position: ________________________________________
School Information : Full Time Student Part Time Student N/A
School Attending: ____________________________________________________________________
Emergency Contact Info:
Name: ________________________________________ Relationshi p __________________ Phone :
(_____) ______-_______
Formal Education (Highest year of school completed):
Some high school GED High school Some college College Post-graduate Other____________
What is your primary Language? English Spanish Signing French Other _________________
Do you speak another Language? French Signing Spanish Other __________________________
Ethnicity : African-American Asian-American Caucasian Latino Native American Other__________
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.

Referred by : Flier Friend Internet Newspaper Radio National media NCASAA Other_______
Do you drive? Yes No
Do you have regular access to a car? Yes No
References:
Please list five references of people who know you well, other than relatives, preferably for whom you have worked in either a paid or volunteer capacity:
Name: ___________________________________________ Phone: (_____) ______-_______
Address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________
Name: ___________________________________________ Phone: (_____) ______-_______
Address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________
Name: ___________________________________________ Phone: (_____) ______-_______
Address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________
Name: ___________________________________________ Phone: (_____) ______-_______
Address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________
Name: ___________________________________________ Phone: (_____) ______-_______
Address: _______________________________________________________________ Apt: __________
City: _____________________ State: ___________ ZIP: _____________
Why do you want to become a CASA volunteer?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________
Skills and Interests:
Do you have experience working with children? Yes No
What strengths do you feel you have that you will utilize in working as a CASA volunteer?
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.

What weaknesses do you feel you will have in working as a CASA volunteer?
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________
Present membership in clubs or organizations (include responsibilities and offices held):
_______________________________________________________________________________________
_______________________________________________________________________________________
Previous membership in clubs or organizations (include responsibilities and offices held):
_______________________________________________________________________________________
_______________________________________________________________________________________
Volunteers typically put in 10-15 hours per month on their case. They are able to work most of their case after hours and on the weekends. However, a volunteer may have a court hearing every 3 to 4 months. These hearings usually last 1-2 hours during the weekday. A Volunteer is notified of the date and time in advance, and is encouraged to attend these hearings during the day with their CASA
Case Supervisor. Would your employer allow you to attend your court hearings?
Yes No
Please explain: _______________________________________________________________
Are you available to complete 30 hours of initial volunteer training?
Yes No
Most of our children are placed in foster homes, group homes or residential treatment centers out of
Walker and San Jacinto Counties. Can you see yourself visiting a child in one of these placements?
Yes No
There are some cases where the family is still involved in the case. Can you see yourself visiting a family in their home?
Yes No
CASA Volunteers are required to keep up their education in the advocacy field. CASA of Walker &
San Jacinto Counties provides ongoing training for their volunteers. Will you be available to attend
12 hours of continuing education per year?
Yes No
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.

PLEASE COMPLETE ALL QUESTIONS AND GIVE DETAILS AS NEEDED:
1. Have you ever been charged and/or convicted of a misdemeanor? Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
2. Have you OR an immediate family member ever been charged and/or convicted of a felony?
Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
3. Have you ever been or are you currently on probation and/or parole? Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
4. Any DWI/DUI arrests or convictions? Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
5. Have you ever had your driver’s license revoked or suspended?
Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
6. Do you now or have you ever had a substance dependency/abuse problem? Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
7. Do you have any kind of health impairment?
Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
8. Have you ever or do you now engage in sexual misconduct, which, if known, could cause harm
to a child, to you, or to CASA of Walker, San Jacinto & Trinity Counties?
Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
9. Have you ever been charged with or convicted of sexual misconduct (including pornography)?
Yes No
If yes, please explain: __________________________________________________________________
_______________________________________________________________________________________
10. Do you consent to a routine check of your criminal records?
Yes No
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.

DISCLOSURE
BACKGROUND/CRIMINAL HISTORY CHECKS
I acknowledge:
As part of the application process as an employee or volunteer, CASA of Walker, San Jacinto & Trinity
Counties will obtain state and national criminal history check s which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living.
AUTHORIZATION
During the application process and at any time during the tenure of my employment or volunteer association with CASA of Walker, San Jacinto & Trinity Counties, I hereby authorize ChoicePoint WorkPlace Solutions
Inc., on behalf of CASA of Walker, San Jacinto & Trinity Counties to procure a national criminal history which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from court record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.

I hereby certify that I am interested in becoming a CASA volunteer and know of no reason why I should not be assigned to a child in the CASA program. I am aware that the children in the CASA program have been abused, neglected or abandoned by adults, and since I do not want to be another cause of disappointment to the child(ren), I agree to a minimum of one (1) year commitment to the child(ren) and case to which I am assigned.
THE UNDERSIGNED ACKNOWLEDGES AND AGREES THAT:
1. He/She is not obligated, if called upon, to accept a case herein applied for, and that
2. CASA of Walker, San Jacinto & Trinity Counties is not obligated to assign or actively seek to assign him/her to a case, and that
3. As a part of CASA of Walker, San Jacinto & Trinity Counties’ policy, additional personal information will be gathered during the pre-interview process, and that
4. CASA of Walker, San Jacinto & Trinity Counties retains the right to deny acceptance to any individual whom, in CASA’s judgment, may not serve the best interests of the program, and further, CASA is not required to state the reason(s) for non-acceptance, and that
5. Any advocate found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sexual offense, child abuse or neglect, or related acts that would pose risks or threats to a child(ren) in the CASA program or to the credibility of the CASA of Walker, San Jacinto & Trinity Counties program is not accepted as a CASA volunteer.
6. The volunteer’s file will be held in strict confidence and becomes the property of CASA of Walker, San
Jacinto & Trinity Counties.
CASA of Walker, San Jacinto & Trinity Counties reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. The CASA program rejects 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 the CAS A program’s credibility.
I HAVE TRUTHFULLY RESPONDED TO ALL OF THE QUESTIONS ON THIS APPLICATION.
_________________________________________
Applicant’s Signature
Date: ____ / ____ / _____
PLEASE SUBMIT A COPY OF YOUR DRIVER’S LICENSE
WITH YOUR COMPLETED APPLICATION.
BACKGROUND CHECKS
TX Dept. of Public Safety Criminal
TDFPS Central Registry
LexisNexis (Volunteer Select)
State Sex Offender Registry
Natl. Sex Offender Registry
Personal Reference #1
Personal Reference #2
Personal Reference #3
DATE CHECKED DATE RETURNED
EQUAL OPPPORTUNITY STATEMENT
It is the policy of CASA of Walker, San Jacinto & Trinity Counties to implement affirmatively equal services to all clients without regard to race, religion, sexual orientation, group, age, gender or national origin.