Name:

Address:

Phone(home):

Phone(other):

Your Email:

Date of Birth:

Emergency Contact Information:
(Name, Relationship, Address and Phone Number):

Do you drive?
 Yes No
Do you have regular access to a vehicle?
 Yes No

Highest Level of Education:

Name and Address of Current or most recent Employer:

Brief Description of professional responsibilities:

Volunteer History (list name of organization and volunteer role):

Do you speak any languages other than English?
 Yes No
Language:

Hobbies/Special Interests:

When would you be available for volunteer services?

Are you willing to obtain criminal and child welfare clearances?
 Yes No

Have you ever been arrested for a crime?
 Yes No
Explain:

Approximate amount of weekly time to volunteer with CASA:
.

How did you learn about CASA?

Personal Reference (Please include Name, Address and a Phone Number):

1.

2.

3.

Please provide a statement explaining why you want to volunteer with CASA and work with abused and neglected children

AFFIRMATION and RELEASE

I, the undersigned, hereby affirm that all of the answers provided on my volunteer application are true and correct. I hereby authorize Erie County CASA, Inc., to investigate my background by utilizing the information I have provided on this application to determine my fitness as a potential volunteer.

I understand the information requested in this application will be used only for the purpose of determining suitability as a CASA volunteer.  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.  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 individuals directly involved in the case or with who will be consulted for their professional knowledge on expertise.

Print Name:
Date: