Casa Volunteer Application Form Page 2
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5Volunteer App w/Releases & Affirmation
______________________________________________________________________________________
Name
Relationship
Age
Place of Employment
______________________________________________________________________________________
Name
Relationship
Age
Place of Employment
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
DHHR HISTORY
An applicant having a pending DHHR investigation may be disqualified as a CASA volunteer. An
applicant having a substantiated allegation of abuse or neglect will be disqualified as a CASA volunteer.
Have you ever been investigated by the Department of Health and Human Resources for abuse and/or
neglect?
___Yes
___No.
If yes, please explain: ___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Have you personally experienced abuse or neglect as a child?___Yes ___ No
If yes, please explain what you have done to recover from it and how you believe it may effect how you
work with children who have been abused.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
CRIMINAL HISTORY
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 will not be accepted as a CASA volunteer.
Applicants with other misdemeanor 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.
Have you ever been arrested for a crime?
Yes ____ No ____
If yes, what was the charge? ______________________________________________________
Date of arrest/Disposition: __________________________ County: ___________________
CURRENT EMPLOYMENT
Current Employer _______________________________________________________________________
Address_______________________________________________________________________________
City/State __________________________________________________ Phone No.__________________
May you be contacted at work? ______ Yes
______ No
Brief description of work _________________________________________________________________
______________________________________________________________________________________
WVCASA Mandatory State Standard I.A. Form
Page 2 of 5
2.2009
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