Advocate Application : How To Help : CASA of Rochester/Monroe County

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Daytime Phone (Required)

email address (Required)

Education- High School

Education- College/grad school

Volunteer Experience- Organization & Dates

Have you lived outside of NYS in past 5 years?

Are you prepared to complete 33 hours of pre-service training and 12 hours/year thereafter?

Can you attend meetings & court dates during the work day? (Required)

Are you prepared to commit to at least two years of volunteer service? (Required)

Languages spoken, other than English

Hobbies/special interests/training

Do you have court cases pending? if yes note type (Required)

Have you been convicted of a crime as an adult? If yes, explain (Required)

Have you been involved with Child Protective services or Family Court? If yes, explain (Required)

Do you hold a valid drivers license?

Do you consent to a routine check of criminal records? (Required)

Reference #1 -Name

First Name *

Last Name *

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Reference #1 Email

Reference #1 - phone

Reference #1- Relationship

Reference #2 - Name

First Name *

Last Name *

Reference #2 - Email

Reference #2 - Phone

Reference #2 - Relationship

Reference #3 - Name

First Name *

Last Name *

Reference #3 - Email

Reference #3 - Phone

Reference #3 - Relationship

Reference #4 - Name

First Name *

Last Name *

Reference #4 - Email

Reference #4 - Phone

Reference #4 - Relationship

I hereby affirm that all of the answers provided on my Volunteer Advocate Application are true. I hereby authorize CASA of Rochester/Monroe County Inc., and other appropriate agencies to provide the necessary information for them to secure the following record checks:

- Criminal records from the court jurisdiction in which the applicant currently resides and works

- State criminal records

- FBI or other national criminal database

- National Sex Offender Registry

- Child Abuse Registry or child protective services where permissible by law

- Social security number verification

If you refuse to sign a release of information form or submit the required information or fingerprints for any of the checks required, the CASA of Rochester/Monroe County, Inc. will not accept your application.

Any applicant found to have been convicted of, or have charges pending for a felony or misdemeanor involving a sex offense, child abuse, child neglect, or related acts that would pose risks to children or our program's credibility is not accepted as a CASA volunteer.

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 two years in the CASA program. 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 materials I will examine in my capacity as a volunteer CASA Advocate. 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.

Signature

Signature Date

Month

Day

Year