Volunteer Application

Name

This field is for validation purposes and should be left unchanged.

Date(Required)

Name(Required)

First Middle Last

Preferred Name/Nickname

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Are you retired?

Yes

No

If yes, list your last employer below

Employer(Required)

Work Address(Required)

Street Address Address Line 2 City State ZIP Code

Title(Required)

Description of Work(Required)

Educational Background(Required)

Include colleges attended and degrees

What languages do you speak?

What do you feel are the personal strengths that you bring to CASA?(Required)

How did you hear about CASA?

Please list below three references

2 professional and/or volunteer contacts and 1 personal. Local references preferred. No relatives, please. Must list addresses.

Name

First Last

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Relationship

Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name(Required)

First Last

Phone(Required)

Relationship(Required)

By Submitting this Form

I understand that the CASA program will require that I complete at least one (1) personal interview and a criminal records check and that my application does not ensure acceptance into the CASA program. I further understand that I may be requested to attend mandatory training as established by the CASA program. I hereby certify that all statements made on this application are true and correct to the best of my knowledge. I understand that by submitting this application, I authorize inquires to be made concerning my employment, character, and police records for the purpose of determining my suitability as a CASA volunteer. All information will be held in confidence. My signature authorizes the Nebraska Department of Health and Human Services to release information to the CASA Program regarding me which may be listed on Nebraska Child Abuse and Neglect Central Register. The Department may state if my name IS or IS NOT on the Register for incidents of Child Maltreatment.

Please list below three references

By Submitting this Form

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