Dear Prospective casa advocate

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Dear Prospective CASA Advocate,

Thank you for your interest in becoming an advocate with our program, CASA of McLennan and Hill Counties. Attached is the application and necessary background check forms that you will need to complete in order to become a CASA Advocate. After your application is completed, please contact me to schedule a pre-training interview. Applications can be brought to your pre-training interview, can be emailed or physically mailed to the following address:

Mindi Masten

2223 Austin Avenue, Suite D
Waco, Texas 76701
mmasten@casaforeverychild.org

Again, thank you for your interest in becoming the voice for an abused and neglected child. I look forward to your involvement with CASA. Should you have any questions or need assistance completing your application, please feel free to contact me at 254-304-7982.

Mindi Masten

Community Outreach Coordinator & Advocate Recruiter and Trainer

PHOTO
(Optional)
ADVOCATE APPLICATION
CASA of McLennan and Hill Counties

2223 Austin Avenue, Suite D

Waco, Texas 76701

254-304-7982

www.casaforeverychild.org

Date of Application: _________________________

First Name: ________________________________ Last Name: _________________________

Address: ______________________________________________________________________

Home Phone #: _________________________ Mobile/Other Contact #: __________________

Email Address: _________________________________________________________________

Date of Birth: _______/ _______/ _______ Age at time of Application: ____________________

Social Security Number: _______________ Circle One: MALE FEMALE

Drivers License #: _____________________ State: ____________________________________

Place of Birth: __________________________________________________________________

Hair Color: ___________________ Eye Color: ___________________ Height: _____ ft. ____in.

How did you hear about CASA of McLennan and Hill Counties?

____________________________________________________________________________________________________________________________________________________________

Employer: _____________________________________________________________________

Employer’s Address: ____________________________________________________________

Job Title: ______________________________________________________________________

If employed, may we contact you at work? YES NO

What is your current employment status?

FULL TIME RETIRED PART-TIME: Hours/Week _____ OTHER: _____

Please list your last three places of employment (the first being your present employer):

Name of Company	Phone #	Position	Supervisor	Dates of Employment	Reason for Leaving

EDUCATIONAL INFORMATION: (Please Circle)

High School: 9 10 11 12

College: 1 2 3 4

Graduate: 1 2 3 4

Are you currently enrolled in school? YES NO If yes, are you: FULL-TIME PART-TIME

What is your expected graduation date? ______________________________________________

Major: ____________________________________ Degree: ____________________________

Please Circle Any Language You Can Communicate In:

ENGLISH SPANISH CHINESE PORTUGESE

JAPANESE TAGALOG VIETNAMESE OTHER

PERSONAL INFORMATION:

Do you have any personal or professional experience with counseling or therapy? YES NO

If yes, please elaborate: ___________________________________________________________

______________________________________________________________________________

List any community groups in which you are presently active (professional associations, faith communities, service organizations, etc.): _____________________________________________

______________________________________________________________________________

Do you give CASA of McLennan and Hill Counties permission to obtain information from these organizations regarding your membership? YES NO If no, please explain: ____________

______________________________________________________________________________

Do you have any experience working with children? YES NO If yes, please explain:

______________________________________________________________________________

Are you a member (current or alumni) of Kappa Alpha Theta Sorority? YES NO

Have YOU or YOUR FAMILY had personal/professional experience with:

(If yes, please provide a brief explanation)

Child Abuse NO YES ___________________________________________

Foster Care NO YES ___________________________________________

Juvenile Court System NO YES ___________________________________________

Child Protective Services NO YES ___________________________________________

Other Child Svcs/Agencies NO YES ___________________________________________

Have you ever applied with another organization that works with children? YES NO
Were you accepted? YES NO If yes, please list the name(s) and year(s): ______________

_____________________________________________________________________________

Have you ever applied to this or another CASA program before? YES NO If yes, please explain: _______________________________________________________________________

Current Marital Status: (please circle)

SINGLE MARRIED Date: _________ SEPARATED Date: __________

COMMITTED RELATIONSHIP WIDDOWED Date: __________

If married/committed, what is your spouse or partner’s name? ____________________________

Spouse/Partner Employer & Position: _______________________________________________

Who is your emergency contact: ____________________ Phone #: _______________________

Please answer the following questions and give details & explanations if the answer is yes:

Have you ever been hospitalized for an emotional issue? YES NO
Have you ever used illegal drugs? YES NO
Have you ever abused illegal drugs or alcohol? YES NO

Details: _______________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

CRIMINAL HISTORY

CASA of McLennan and Hill Counties will ask all volunteers to complete a criminal records check which will reveal any arrest, charge, or conviction. Please respond to the following questions so that this history can be discussed and evaluated.

IF YOU ANSWER YES TO ANY OF HT EFOLLOWING QUESTIONS, PLEASE OFFER AN EXPLANATION IN THE SPACE PROVIDED BELOW.

Have you or any of your family ever been involved in a legal action in McLennan or Hill Counties?	YES NO
Have you ever been arrested or charged with a misdemeanor?	YES NO
Have you ever been convicted of a misdemeanor?	YES NO
Have you ever been arrested or charged with a felony?	YES NO
Have you ever been convicted of a felony?	YES NO
Have you ever been or are you currently on parole?	YES NO
Have you ever been convicted of a traffic violation?	YES NO
Have you ever had any DWI arrests, charges, or convictions?	YES NO
Have you ever had your driver’s license revoked or suspended?	YES NO
Have you ever been arrested or charged with any sexual misconduct (including pornography)?	YES NO

Details:

______________________________________________________________________________

The following questions are for statistical purposes only. Please circle the choice or choices that best describe you:

Ethnic Origin	Native American	Hispanic/Latino	African American/African	Caucasian
Bi-Racial/Multi-racial	Asian/Pacific Islander	Not Known	Other: (Please state)	Decline to State

Please respond to the following statements/questions:

I am interested in working with children and families as a CASA Advocate because: ___________

_____________________________________________________________________________

I feel that I can be a fair and objective advocate for a child because: ________________________

_____________________________________________________________________________

My current hesitations or concerns regarding my participation in the CASA program at this point are: __________________________________________________________________________

______________________________________________________________________________

When would you like to start your CASA Advocate Training? ____________________________

______________________________________________________________________________

We ask that our advocates give 10-12 hours a month to their case/advocate work as a CASA. How do you think you will fit this time into your schedule? ___________________________________

______________________________________________________________________________

PLEASE PROVIDE COMPLETE CONTACT INFORMATION FOR FIVE (5) NON-FAMILY REFERENCES THAT HAVE KNOWN YOU FOR AT LEAST ONE (1) YEAR.

Please do not list a relative, significant other, or two people from the same household. CASA of McLennan and Hill Counties will send an email correspondence with a form for them to complete and return. Reference’s emails will only be used for this correspondence and for no further purpose.

Name:

Email:

Address (if no email):

Relationship To You:

Name:

Email:

Address (if no email):

Relationship To You:

Name:

Email:

Address (if no email):

Relationship To You:

Name:

Email:

Address (if no email):

Relationship To You:

Name:

Email:

Address (if no email):

Relationship To You:

CONFIDENTIALITY OATH

In the best interest of the clients served that are served by CASA of McLennan and Hill Counties, I, _______________________________ (print name clearly) do hereby solemnly promise and pledge that I will faithfully, and to the best of my ability, preserve the confidentiality of any and all information learned, holding all such matters in the strictest confidence, never to be divulged or discussed outside the CASA of McLennan and Hill Counties offices.

________________________________ _______________________________
Signature Date

________________________________ _______________________________

Witness (anyone 18 years or older) Date

MEDIA RELEASE

I, _______________________________________ (print name clearly), will allow CASA of McLennan and Hill Counties to use my name in print and/or electronic media and/or videos of me for the promotion of its program as applicable.

________________________________ _______________________________
Signature Date

________________________________ _______________________________

Witness (anyone 18 years or older) Date

Personal Inquiry Waiver
Authority for Release of Information

I respectfully request and authorize local, state and federal criminal justice agencies to release to CASA of McLennan and Hill Counties, any and all information that you may have concerning me, my work record, school record, and/or reputation. This information provided is for the sole purpose of determining my qualifications and fitness for the position I am seeking with CASA of McLennan and Hill Counties.

I further authorize a personal background check, criminal history information check, and driving record check to be conducted on my person through sources to include, but not be limited to, the local Police Department and the Texas Criminal Information Center (TCIC)/National Crime Information Center (NCIC) to determine my eligibility for advocate status with CASA of McLennan and Hill Counties. This executed personal inquiry waiver shall allow CASA of McLennan and Hill Counties to complete any number of required background checks as needed as long as I am active with the CASA program.

I hereby release you, your organization, CASA of McLennan and Hill Counties, and others from any liability or damage that may result from furnishing the information requested above.

This form must be notarized. Do not sign until time of notarization.

Full Name of Applicant: __________________________________________________________

(Please Print Clearly)

Address: ______________________________________________________________________

______________________________________________________________________________

Driver’s License # ________________ State: ________ Date of Birth ______/______/______

Signature of Applicant: ________________________________ Date: _____________________

Subscribed and sworn to before me this ______________ day of _________________, ________

____________________________________________
Signature of Notary Public

(seal)

My commission expires _________________________ _____________________

Date Completed

1/1/2015 Personal Inquiry Waiver – Criminal Background Check

Insert DFPS Background Check Form Here

FBC IDENTIFYING INFORMATION FORM

The following information is required to obtain the fingerprint based background check. This information will be provided to the Texas Department of Public Safety, the state entity that administers the fingerprint-based background check.

Name
DOB
Sex
Race
Ethnicity
Skin Tone
Height
Weight
Eye Color
Hair Color
Place of Birth
Home Address

This information will only be used to obtain the required FBC. Following the receipt of the check results, you may select the actions of the CASA program regarding this information:

Please select one of the following two options:

□ I would like the original form returned to me.
(Persons selecting this option will receive the original form back via US Mail)

□ I would like the CASA program to destroy the form.

________________________________________________ ____________________
Signature Date

CASA OF MCLENNAN AND HILL COUNTIES TRAINING AGREEMENT

Prospective advocates are asked to read and sign the following training description and agreement:

DESCRIPTION:
The initial training consists of 32 hours broken down into 30 hours of classroom time and 2 hours of courtroom observations.

AGREEMENT:

I understand that participation in the Pre-Service Advocate Training is required and essential, and includes 30 hours of classroom time.
I understand that, in addition to the classroom sessions, I will be required to complete 2 hours of courtroom observation at the Bill Logue Juvenile Justice Center or the Hill County Courthouse.
ATTENDANCE – I understand that one (1) class can be missed during the pre-service training and that has to be approved by the CASA Recruiter and Trainer.
I am aware that the Pre-Service Training Class is part of the screening process and that acceptance to participate in training does not guarantee that I will be sworn in as a CASA or that I will be assigned to a case. I further understand that either I or CASA can choose to discontinue my involvement in the training/screening process at any time without further obligation on the part of either party.
Upon completion of training, my participation in the training process, as well as other screening material (returned reference forms, criminal record check, DFPS Central Registry check) will be reviewed for the purpose of determining my eligibility to be assigned a case as a CASA.

I understand and am willing to meet all the conditions stated above, and wish to participate in the CASA Pre-Service Training.

_________________________________________________ _______________________

Signature of Prospective Advocate Date

The undersigned acknowledges and agrees that:
I am interested in becoming a CASA advocate and know of no reasons why I should not be assigned to a child in the CASA Program. I am aware that the children CASA serves have been abused, neglected, or abandoned by adults. I do not want to be another cause of disappointment to a child and acknowledge that I will make a commitment of at least one year to the child(ren) and case to which I may be assigned.

As a CASA Advocate, I will be willing to: (Please Circle YES or NO)
Commit a minimum of a year to being a CASA Advocate YES NO
Participate in CASA’s Advocate Training Program YES NO
Participate in further training as offered to Advocates YES NO
Visit in person with the child(ren) to which I may be assigned YES NO
Prepare written reports to the court with the guidance and assistance of CASA YES NO
Participate and attend court hearings and meetings on a child’s case YES NO

I understand that I will need to carry liability insurance on my car. I agree to maintain this minimum liability insurance throughout my participation with the CASA program. I understand that I may transport a child during the course of my CASA duties and must maintain proof of active liability insurance and current driver’s license in my CASA file.

As an applicant to CASA of McLennan and Hill Counties, I understand and acknowledge that:

CASA of McLennan and Hill Counties is not obligated in any way to accept me as an advocate into the program by submission of this application.

CASA of McLennan and Hill Counties retains the right to refuse any individual they feel would not be in the best interest of the program and further, CASA is not required to state reason(s) for non-acceptance into the program.

CASA of McLennan and Hill Counties will hold all information in the advocate’s file in strictest confidence. Such information becomes property of the CASA Program.

I authorize CASA of McLennan and Hill Counties to conduct all background checks necessary to insure the safety and suitability of all program clients and participants. I agree that the results of all background checks will be sent directly to the office of CASA of McLennan and Hill Counties.

I give permission to CASA of McLennan and Hill Counties to release information about my application, acceptance, and/or participation in the program to any other CASA program to which I apply in the future.

I have truthfully responded to all of the questions on this application.

____________________________________________________ _____________________
Signature of Prospective Advocate Date

Directory: fileLibrary
fileLibrary -> Ordination and licensing policies and procedures
fileLibrary -> Fishbone – The Cause and Effect Diagram Source: Iowa Evaluator Approval Training Program (adapted) See Also: The Handbook for smart school Teams, pp 136-137 What Is It?
fileLibrary -> 1920’s and 1930’s Inductees joseph c. Gargano, 1927

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