Court Appointed Special Advocates (CASA) of Pulaski County

Board Application

Last Name:

First Name:

Date of Birth:

Gender / Race:

Social Security Number:

Drivers License Number:

Home Address:

City / State / Zip:

Home / Work / Cell / Fax:

Email Address:

Social Networks (twitter / facebook / linkedin / etc. (List All):

Current Employer:

Do you mind recieving phone calls at work?:

• Yes
• No

Current Community Activities:

List Current and previous volunteer work (include a brief description of duties and acticites and dates of service):

As a board member, you will be expected to help raise awareness and funds. Will you be able to commit to this?:

• Yes
• No

Are you willing to make a commitment for at least one year?:

• Yes
• No

Whta are you reasons for wanting to be involved with Pulaski County CASA?:

Do you have any personal experience involving the following items?:

• Fundraising
• Marketing
• Event Planning
• Other board related activities

If so, please explain the above checked responses:

How did you learn of our program?:

Have you ever been convicted of a crime other than a traffic violation?:

• Yes
• No

If yes was checked, what was the charge, date convicted and where:

CASA National Standards state that any applicant found to have been convicted or having pending charges involving a sex offense, child abuse or neglect, or related acts will not be accepted as a board member. Do you understand the above statement?:

• Yes
• No

Are you an American Citizen?:

• Yes
• No

If not, please explain:

CASA conducts background checks on all volunteer applicants. Background checks include, but are not limited to, a Central Registry Check, a National and State Criminal History Check, a Sexual Offender Registry Check and local law enforcement inquiries. Do you grant Pulaski County CASA full permission to perform all applicable background checks upon receipt of this application as well as routine checks in the future should you be accepted as a CASA Board Member?:

• Yes
• No

My typed name below will act as a signature for the above question:

Please list three people, other than your relatives, who know you very well. These references preferably need to be people with whom you have worked in either paid or volunteer capacity. If you are currently working, either paid or as a volunteer, please include the name of your supervisor. Also, for each reference you have listed below, have them complete one of the reference forms by either downloading the form from our website, or by completing the form online under the forms section (By supplying the names you are giving that person permission to complete the reference form):

Please provide the name and phone number of someone we can contact in case of an emergency. You may list more than one person. (Name and phone number please):

Pulaski County CASA reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work. All information obtained will be held in confidence. Please type your name below which will be deemed an offical signature.:

Todays Date:

ex. mm/dd/yyyy