Fillable Casa Volunteer Application Form (Page 5 of 5) in pdf

Volunteer App w/Releases & Affirmation

Affirmation and Release of Information for Background Check

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

CASA program’s credibility is not eligible to be a CASA volunteer.

I, _________________________________ hereby affirm that all of the answers provided on my volunteer

application are true. If I have misrepresented any information on this application I will be immediately

disqualified.

Further, I hereby authorize West Virginia CASA and any agency West Virginia CASA authorizes, to

investigate my background to determine my fitness as a potential volunteer.

I further authorize the Department of Health and Human Resources to conduct a record check and to

release the results of said records check to the ___________________ CASA Program. I understand that

the information requested in this application will be used only for the purpose of determining my suitability

as a CASA volunteer.

Further, I understand that completion of training does not guarantee that I will be assigned a case. If I have

successfully completed the training and have met all other requirements, and it has been determined that I

am a suitable volunteer, I understand that I will be expected to serve a minimum of one year in the CASA

program. That year begins on the date of my swearing in by the Judge. If unforeseen circumstances

prevent me from fulfilling this obligation, I will submit my written resignation to the program director with

as much advance 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

directly involved in the case or who will be consulted for their professional knowledge and expertise.

I also understand that if for any reason it becomes apparent that my activities are contrary to the policies,

goals and/or philosophy of the CASA program and their desire to provide quality services to abused and

neglected children, my services as a CASA volunteer will be terminated.

I submit the statements on this application are true, complete, and correct to the best of my knowledge. I

understand that falsification on this application can disqualify me from consideration or can result in

dismissal at a later time.

I have read the above waiver and release statement and fully understand what rights I am waiving by

signing this document.

I attest to the fact that I have never been charged or convicted of child abuse including sexual, emotional, or

physical; neglect; or any other crime against a child. I attest to the fact that I have been convicted of no

other crimes, except as listed.

CHARGE/CONVICTION

______________________________________________________________________________________

Your Signature _______________________________

Date _________________

WVCASA Mandatory State Standard I.A. Form

Page 5 of 5

2.2009

Casa Volunteer Application Form Page 5