Apply : 11th Circuit CASA Program : Local CASA Programs : Missouri CASA Association

CASA in St. Charles County

11th Circuit CASA Program Online Volunteer Application

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone (Primary) (Required)

Phone (Mobile)

Email (Required)

SSN

You may opt to provide this information to the program offline.

Driver's License # (Required)

Marital Status (Required)

Spouse's Name

Spouse's Employer

Do you have children? (Required)

If 'Yes,' what are their names and ages?

Does anyone else live in your household? (Required)

If 'Yes,' please provide their name/relationship/age

Length of Residency in St. Charles County (Required)

Please enter in months and years.

Length of Residency in Missouri (Required)

Please enter in months and years.

If you lived in another state, please list city, state, and time period in the other state(s)

Are you currently employed? (Required)

Can you be called at work?

Current Employer (if applicable)

Dates of Employment

Current Employer's Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Previous Employer

Dates of Employment

Previous Employer's Address

Country

Address Line 1

City

State/Province

Postal Code

Education - Please List Your Highest Level of Education (Required)

Current Community Activities (Please List)

Languages Spoken (Other Than English)

Tell Us About You - Please List Hobbies and Special Interests (Required)

Have you every been arrested for a crime? (Required)

If 'Yes,' please list the date of the arrest, the charge(s), and disposition

Volunteer History

Please list all volunteer experience, including the organization, address, date(s) of service, and your position within the organization

Personal References (3) - Non-Relatives Only

Reference 1

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email (Required)

Relationship (Required)

Reference 2

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email (Required)

Relationship (Required)

Reference 3

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email (Required)

Relationship (Required)

How did you hear about us?

Please tell us how you heard about the CASA program (Required)

Accessibility

Do you drive? (Required)

You will need to provide a copy of your license for the CASA program.

Do you have access to a vehicle? (Required)

Do you have automobile insurance? (Required)

You will need to provide a copy of your insurance card for the CASA program.

Can you think of any reason why you may be impeded to advocate for a child? (Required)

If 'Yes,' please explain

Information necessary for criminal and child abuse/neglect record checks.

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Name

First Name *

Last Name *

DOB/Sex/Race (Required)

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Home Phone (Required)

Work Phone

ext Extension

Fax

Email (Required)

Social Security Number

You may opt to provide this information to the program offline.

Driver's License Number (Required)

Note:

A candidate for CASA volunteer status will be eliminated from consideration if he/she:

1. fails to possess the requisite disposition for the position;

2. made a false statement on the application or in the interview;

3. has conflicting interests which may impair or compromise work with the CASA Program and/or Court;

4. has a verified criminal record history that would disqualify him/her for employment with the Court;

5. has a verified history as a perpetrator of child abuse and/or neglect; or

6. fails to complete the pre-service training program.

Affirmation and Release

I hereby affirm that all of the answers provided on this application are true. I hereby authorize the 11th Circuit CASA Program to investigate my background to determine my fitness as a potential 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:
     • the background investigation includes, but is not limited to, fingerprints to check a national criminal history records check of the FBI;
     • Officials will be using the FBI criminal history record (if one exists) to make a determination of the applicant’s suitability as a CASA Volunteer. The applicant      will be provided an opportunity to complete or challenge the accuracy of the information in the record.
     • Procedures for obtaining a change, correction, or update of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34;
     • The applicant will be afforded a reasonable time to correct or complete the record unless he/she has declined to do so;
     • The criminal history record will be solely used for the purpose requested and will not be disseminated outside of the 11th Circuit CASA Program;
     • A criminal record background check and a child abuse/neglect report background check will be completed.

Further, I understand that after the successful completion of my training, I will be expected to serve a minimum of one year in the CASA program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the CASA Coordinator 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 volunteer Court Appointed Special 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.

Affirmation Date (Required)

Please select today's date.

Signature (Required)

Please type your full signature. You may be required to provide a physical signature to the CASA program.

11th Circuit CASA Program
1700 South River Road
St. Charles, MO 63303

Email: michelle.barron@courts.mo.gov | Phone: (636) 949-3040, ext. 4564

Hours: M-F 8:00 AM to 4:30 PM