Volunteer Certification Application [return]    

Volunteer Certification Application

Any willful omission or misrepresentation of any fact required to be disclosed in this application or any accompanying statement may result in certification (initial or ongoing) denial. This is pursuant to the Administrative Code Sections governing Court Appointed Special Advocates in Arizona.

Complete all questions of this application and fulfill all other requirements mentioned in the instructions.

Section I - Applicant Qualifications
I am a U.S. Citizen or Legal Resident.
Applicants who are employed by DES, the Juvenile Court or child welfare agencies may serve as a CASA volunteer if authorized by a Juvenile Court judge. Are you employed by DES, the Juvenile Court or child welfare agency?
I am at least 21 years of age.
Section II - Applicant Information
Legal First Name: Middle Initial: Legal Last Name: AKA/Alias:

Address:
City: State: Zip Code:
County: PO Box:
Home Phone: Cell Phone:
Fax:    
Email:
May we distribute your name, address, and telephone numbers to other CASA volunteers?
Additional information needed for a criminal background information check
Height: ft. in.
Eye Color:
Ethnicity:
Weight: lbs.
Hair Color:
Select Gender:
Date of Birth:
Place of Birth:
In case of an emergency, whom should we contact for you? (List name, phone number and relationship)
First Name:
Phone Number:
Last Name:
Relationship:
List relevant work or volunteer experience:
Other than English, list languages in which you are fluent (if any):
List any affiliation which relates to the foster care system: (Example: adoption, child advocacy):
There are opportunities other than child advocacy assignments to assist the Arizona CASA Program, such as administrative office work, public speaking and writing newsletters. If you would be interested in serving in any of these or other capacities, please list them:
Section III - Employment Experience (List Current Employment)
Company Name: Position Title:

Address:
City: State: Zip Code:
Hours Worked:
Work/Week:
Days Off:
Position Duties:
Section IV - Vehicle Information

You may be transporting children and families in the course and scope of your volunteer work. Therefore, additional vehicle information is requested. Upon acceptance into the program, you will need to inform your insurance carrier that you are transporting people in your volunteer work and provide proof of insurance to the county coordinator on an annual basis.

Access to Vehicle?
Section V - Background Information

If you answer "yes" to any of the following questions, explain the nature and details of the case, the charge, and criminal history disposition.

1. Have you ever been convicted of any crime in this state or any jurisdiction?
2. Do you have any charges pending or are you currently awaiting trial for a felony?
3. Have you ever been convicted of a felony?
  The fact that you entered into a plea bargain or pled "no contest" or that your conviction has been vacated, pardoned, expunged, dismissed, appealed or that your civil rights have been restored does not mean that you can answer the question "no". You Must answer "yes" and provide the details of the offense and explain.    
4. Are you currently on probation, parole or community supervision for a felony offense?
5. Have you ever had disciplinary action taken against you by any state or federal court, administrative or regulatory agency, or by any professional licensing disciplinary board? (Examples: administrative orders, reprimand, censure, fine or other penalty).
6. Have you been found in any professional licensing disciplinary board's final decision to have sexually or physically abused or exploited any minor, developmentally disabled person, or vulnerable adult?
7. Has there been a finding against you in a civil, probate, domestic relations or dependency or other court case, that you have sexually assaulted, exploited or physically abused any child or vulnerable adult?
8. Have you used any non-prescribed controlled substances and/or illegal drugs, including marijuana, within the past two (2) years?
9. Are you currently using any non-prescribed controlled substances and/or illegal drugs, including marijuana?
10. Are you the parent or guardian of a child currently in the dependency process or adjudicated to be dependent?
11. Do you have a record in the DES Central Registry of substantiated acts of abuse or neglect?
12. Are you currently named in an outstanding arrest warrant?
  A "yes" answer to any of the following questions does not necessarily disqualify you from serving as a CASA volunteer.    
13. Have you ever been convicted of a misdemeanor?
  The fact that you entered into a plea bargain or pled "no contest" or that your conviction has been vacated, pardoned, expunged, dismissed, appealed or that your civil rights have been restored does not mean that you can answer the question "no". You Must answer "yes" and provide the details of the offense and explain.    
  Do not answer "yes" if you have only minor civil traffic violations.    
14. Have you ever been convicted of a violation of A.R.S. § 28-1381, § 28-1382, or § 28-1383? (These statutes deal with driving under the influence.)
15. Do you have a record of conviction by final judgment of a misdemeanor involving moral turpitude? (Example shoplifting, writing bad checks, trespassing, etc.)
16. Are you the subject of an allegation or investigation in any criminal matter?
17. Do you have any charges pending or are you currently awaiting trial for any misdemeanor?
18. Have you ever been found liable in a civil lawsuit which included an allegation of misrepresentation, fraud, misappropriate, material omission, theft or conversion?
19. Do you have a record of any act constituting dishonesty or fraud? (Examples would include, but would not be limited to, charges of plagiarism, lying under oath, or cheating on an exam.)

If you answered "Yes" to any of the Background Information questions, please give a brief explanation:
Section VI - Personal References(List 3 nonrelative persons or significant other not residing in the same household). Email address required for all references.
First Name: Last Name: Relationship:
Email:

Address:
City: State: Zip Code:
Personal References Continued
First Name: Last Name: Relationship:
Email:

Address:
City: State: Zip Code:
Personal References Continued
First Name: Last Name: Relationship:
Email:

Address:
City: State: Zip Code:
Section VII - Personal References
I hereby submit this application to the State of Arizona Supreme Court, Court Appointed Special Advocate (CASA) Program. This application is for certification as a CASA volunteer under the provisions of A.R.S. § 8-522 providing for CASA volunteers.
I understand that background investigations including criminal history, a polygraph exam, Department of Economic Security (DES) Central Registry Information, and Motor Vehicle Records are some of the screening procedures and are conducted on all applicants including the recertification process. I consent to the background check and all components stated above for the purpose of aiding such a background investigation. I agree to submit to this procedure with the knowledge that the results of this investigation are a determining factor in obtaining certification as a CASA volunteer.
In submitting this application, I further agree to abide by all confidentiality laws as of the date of this application. I understand that my application does not ensure acceptance into the Arizona CASA Program. I also understand that the Arizona CASA Program reserves the right to disqualify any applicant who would not be a good match for this volunteer position. Service as a CASA volunteer is by grace and not by right. I understand that the Arizona CASA Program reserves the right to terminate the service of a volunteer for any reason.
The filing of an application which is false or misleading may result in denial, suspension, or revocation of a certification.
I affirm my statements on this application are true and correct. I have disclosed all aspects of my criminal and background history that would affect my participation in the program.
Statistical InformationWe have a program of applicant information research. The information you provide on this form will assist the Arizona CASA Program in evaluating recruitment and selection procedures. Information provided will not be used in any way to affect the application process, rating, or employment, nor will it be supplied to any hiring authority.


Source:
Source Name:
Education:
Employment:
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