General Info
Are you known by any other names?
Home Address
County
Children's Names
Name
Date of Birth
Living With You?
Other Household Members
Emergency Contact
Are you computer Literate?
Ethnicity
Where did you hear about the CASA of Amarillo Area Program?
Current hobbies and / or interests
Will you be able to take time off work?
Employment History
Education
Select Highest Completed
High School
None
9th Grade
10th Grade
11th Grade
12th Grade
College
None
1 Year
2 Years
3 Years
4 Years
Graduate School
None
1 Year
2 Years
3 Years
4 Years
Personal
List any community groups in which you are presently active
(professional associations, faith communities, service organizations, etc)
Do you have any experience working with children?
If yes, please give organization names and details
Do you give CASA of Amarillo Area permission to obtain information
from these organizations regarding your membership?
If No, please explain
Have you or your family had personal/professional experience with:
Have you ever applied with another organization that works with children?
Have you ever applied to this or any other CASA program before?
IF yes, explain
Please answer the following questions and give details if answer is yes:
Have you ever been hospitalized for an emotional issue?
Have you ever been convicted of a crime?
Have you ever been convicted of traffic DUI/DWI, license revoked, or any sexual misconduct?
Do you now, or have you had a drug/alcohol abuse or dependency problem?
Do you have any kind of health impairment?
Details
Currently on medication??
Have physical or medical limitations?
Please respond to the following:
Please describe your strengths and weaknesses.
I am interested in working with children and families as a CASA volunteer because . . . .
I feel I can be a fair and objective advocate for a child because . . .
Any hesitations or concerns regarding my participation in the CASA program at this point are. . .
Are you willing to commit to one year of volunteer service?
Refrences
Please provide COMPLETE contact information for three non-family references that have known you for at least one year.
Please do not list a relative or significant other. If possible, please list an employer or supervisor.
CASA of Amarillo Area will mail a brochure with a description of the CASA program and reference form for
them to complete and return.
Address
Relationship (how this reference knows you)
Address
Relationship (how this reference knows you)
Address
Relationship (how this reference knows you)
Do you have any training or experience in any of the following: (please check all that apply)
If you checked any of the above boxes, please describe/explain