Volunteer App w/Releases & Affirmation
CASA VOLUNTEER APPLICATION FORM
PERSONAL
Name_________________________________________________________________________________
First
Middle
Maiden
Last
Social Security No._____________________________________
Home Address__________________________________________________________________________
City/State/Zip_____________________________________________ Phone Number_________________
Email address______________________________________ Cell Phone __________________________
Date of Birth________________________________ Place of Birth_______________________________
What county do you live in?_____________________ How long have you lived there?_______________
Have you ever served as a CASA volunteer before? ____ Yes _____ No
Have you ever applied to be a CASA volunteer before? ____ Yes _____ No
Person to notify in emergency______________________________________________________________
Relationship____________________________________ Phone No.______________________________
Please list places of residence for the past 10 years (use back of page if additional space is needed)
______________________________________________________________________________________
City
County
State
Years Lived There
______________________________________________________________________________________
City
County
State
Years Lived There
______________________________________________________________________________________
City
County
State
Years Lived There
Ethnicity:
___African-American
___Hispanic
___Caucasian
___Native American
___Other
Can you think of any reason a Judge may be reluctant to appoint you to a case? ___Yes ___No
If yes, please explain: ___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
How did you hear about our CASA Program? ________________________________________________
Please list all persons living in your home (use back of page if additional space is needed)
______________________________________________________________________________________
Name
Relationship
Age
Place of Employment
______________________________________________________________________________________
Name
Relationship
Age
Place of Employment
WVCASA Mandatory State Standard I.A. Form
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2.2009