Court Appointed Special Advocates (CASA) of Pulaski County

Advocate Application

Last, First Name:

Date of Birth:

Gender / Race:

Social Security Number:

Driver's License Number / State:

Home Address (City, State and Zip):

Home / Cell / Work Phone Numbers:

Email Address / Website / Social Networks:

Current Employer and Address:

Can you recieve calls at work?:

• Yes
• No

Brief Description of Work:

Formal Education (highest year of school completed):

Do you speak a foreign language? (if so what):

Do you drive or have regular access to transportation?:

• Yes
• No

Current Community Activites (Volunteer, Church, Civic Groups, etc.):

List current and previous volunteer work (include a brief description of duties, activites and date of service):

As a CASA Advocate, you will be required to attend court hearings for the children you represent. Will you be able to arrange your schedule to attend these hearings?:

• Yes
• No

Are you willing to make a commitment of one year of advocate service?:

• Yes
• No

What are your reasons for wanting to become a CASA Advovate?:

Do you have any personal experience involving the following items? Child Welfare, Foster Care, Court System, Other agencies offering service to children (If so, please explain below):

How did you learn of our program?:

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

• Yes
• No

If you answered yes, please explain:

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 volunteer advocate. Do you understand the above statement?:

• Yes
• No

Are you an American Citizen?:

• Yes
• No

If you are not a citizen, 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 Volunteer?:

• Yes
• No

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

Can you think of any reason why a judge might be reluctant for you to serve as a CASA advocate:

• Yes
• No

If you answered yes, please explain below:

How long have you lived Arkansas?:

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):

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):

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.:

Today's Date:

ex. mm/dd/yyyy